GERO FINAL, Gero - Lecture 10 (End of Life)

The nurse recognizes a need for further teaching when a 72 year old male client states:

"the hair on my legs is falling out, I must have some disease"

Age-related macular degeneration patho

*Drusen deposits* in retinal epithelium --> atrophy and degeneration of macular cells --> vision impairment

Documentation for delirium should focus on:

*specific indicators of altered mental status* rather than "confused" -Will lead to more appropriate prevention, detection, and treatment to prevent negative outcomes

AD - wandering

-Difficult problem to manage -May be a soothing mechanism -Not well understood Risks: falls, elopement, injury, and death Things to do: music, exercise, refreshments, social interaction -Camouflage doorways, enclosed areas for walking, electronic bracelets, *60% will wander and become lost at some point*

Male sexual dysfunction

-Impotence (erectile dysfunction, or ED) -For most older men, *caused by underlying medical diagnosis and/or the treatment:* 1. Endocrine problems 2. CV problems 3. Depression 4. Neurological problems

Supplemental or Medigap Insurance Policies

-People often purchase supplemental insurance plans because of potentially high co-payments associated with Medicare -Cover only deductibles and part of coinsurance amounts based on Medicare-approved amounts contracted with providers -Example monthly payment - $83 - $168/month

Spiritual nursing responses - nurses can provide psychosocial comfort by:

1. Active listening 2. Sharing fears 3. Provide guidance in the forgiveness of others and self 4. Authentic presence 5. Family support

HF 7 interventions

1. Activity - pace to tolerance 2. Exercise (moderate intensity; start low & work up) 3. Medications -*Calcium channel blockers (CCB) are usually CONTRAINDICATED* -CCBs work by inhibiting the influx of calcium ions through the channels. Need calcium moving through those channels making charges to cause contractions. -*If channels are blocked, force of contractility is decreased.* -*Contractility is already decreased in HF, so CCBs will make it worse.* 4. Sodium restriction to prevent water retention 5. Supplemental oxygen 6. *Daily weight is a good indicator of acute fluid volume status.* -*1 kg weight gain = 1 L of fluid* 7. Possible fluid restriction -*only restrict fluid if pt is stable enough; older adults are more sensitive to fluid volume deficit*

Factors affecting fulfillment of nutritional needs

1. Age associate changes in taste and smell 2. Oral health status 3. Chronic diseases and conditions 4. Side effects of medications 5. Lifelong eating habits 6. Socialization 7. Anorexia of aging 8. Income 9. Transportation 10. Housing *40% - 60% of hospitalized older adults are malnourished or at risk for malnutrition* in the United States due to: -Severely restricted diets -Prolonged NPO status -Insufficient time for feeding assistance

5 leading causes of vision impairment

1. Age-related macular degeneration 2. Cataract 3. Glaucoma 4. Diabetic Retinopathy 5. Optic Nerve atrophy

Clinical features of syndrome of dementia include at least ONE of the following:

1. Aphasia - partial or total loss of the *ability to articulate ideas or comprehend* spoken or written language 2. Apraxia - partial or total loss of the *ability to perform coordinated movements or manipulate objects* in the absence of motor or sensory impairment 3. Agnosia - loss of the *ability to interpret sensory stimuli*, such as sounds or images 4. Disturbances in executive functioning -Attention, decision making, consciousness, memory, problem solving

Nervous system assessment (3)

1. Assess functionality, cognition, BP (orthostatic) -CVA -Alzheimer's Disease -Parkinson's 2. Evaluate hazards in home environment 3. Assess caregiver needs

3 most common care concerns for a person with AD

1. Behavior 2. ADLs 3. Wandering

Oxidative stress theory - free radical theory (5)

1. Cellular errors are result of *random damage from free radicals* 2. Free radicals are natural *by-product of cellular metabolism of oxygen* - they function to destroy bacteria and other foreign substances 3. Accumulation of free radicals is referred to as "oxidative stress" or "oxidative damage" 4. *Mitochondrial DNA most affected* by these changes 5. *Antioxidants neutralize as needed (in youth) BUT as we age, process does not keep up and damage is faster than repair*

Cardiovascular changes 14 CM

1. Decreased cardiac reserve & output 2. Decrease in maximum (peak exercise) heart rate 3. Heart rate 40-100 bpm -*OLDER PTS CHRONICALLY BRADYCARDIC* 4. Slow recovery from tachycardia 5. Fatigue, SOB 6. Increased premature or ectopic (skipped) beats 7. Risk of valvular dysfunction & systolic murmurs 8. *Extra heart sound common: S4 (not S3 which is always abnormal)* 9. Risk of conduction abnormalities 10. Risk of postural & diuretic-induced hypotension 11. Increased systolic blood pressure, pulse pressure, peripheral resistance 12. Risk of carotid artery buckling, jugular venous distension 13. Strong arterial pulses; diminished peripheral pulses; cool extremities 14. Risk of inflamed varicosities

Endocrine changes 5 CM

1. Decreased glucose tolerance, risk of type 2 diabetes 2. Bone mineral density loss with risk of osteoporosis, fractures. 3. Risk of fluid/electrolyte imbalances & postural hypotension 4. Change in body composition with increased fat, decreased muscle & bone mass; decreased strength & functionality with risk of falls 5. Due to adrenal changes, decreased ability to respond to physiological stressors with risk of reduced functionality

3 nursing considerations for eye drop instillation

1. Do not drop directly on the eye - pull lower lid down & apply there 2. Eye can only hold one drop at a time 3. A medication like a beta blocker that's absorbed systemically can lower HR & BP so it's important to allow time for it to absorb in the eye by plugging the inner canthus so that the tear duct is closed and doesn't drain into the sinus cavity and become absorbed.

Hyperthermia prevention (8)

1. Drink 2 to 3 L of cool fluid daily (as tolerated) -important in prevention, as well as in treatment. Person most likely will have sweated out circulating fluid volume. 2. Minimize exertion, especially during heat of day 3. Stay in air-conditioned places, or use fans 4. Wear hats and loose clothing of natural fibers when outside; remove most clothing when indoors 5. Take tepid baths or showers 6. Apply cold, wet compresses, or immerse hands and feet in cool water 7. *Evaluate medications for risk of hyperthermia* 8. Avoid alcohol

3 phases of the silver hour

1. Dying 2. Death 3. Dead

Nervous system changes 2 nursing interventions

1. Educate on safety, avoidance of falls 2. therapeutic communication

MS changes 3 nursing interventions

1. Education on nutrition (calcium), regular exercise, muscle strengthening 2. information on strategies to maximize function -*establish a walking regimen, ROM exercises* 3. fall prevention

3 top chronic diseases in older adults

1. HTN 2. High cholesterol 3. Arthritis

Barriers to completing advanced directives

1. Inaccessible documents 2. Limited education 3. Income -People with a higher socioeconomic status are more likely to have advanced directives 4. Younger age 5. Race

Elders at risk for spiritual distress

1. Individuals experiencing events or conditions that affect ability to participate in spiritual rituals 2. Diagnosis and treatment of a life-threatening, chronic, or terminal illness 3. Expressions of interpersonal or emotional suffering, loss of hope, lack of meaning, need to find meaning in suffering 4. Evidence of depression 5. Cognitive impairment 6. Verbalized questioning or loss of faith -usually older adults get stronger in their faith as they age, but it is not uncommon for them to question it or find new faith 7. Loss of interpersonal support

Temperature monitoring

1. Older adults have a diminished thermoregulatory response - *impairs ability to respond to infection with fever* 2. Frail older adults have *lower baseline temperatures than younger adults* 3. Absence of fever *does not rule out infection; a one degree change from baseline may be significant in older adults* 4. High fevers (≥ 38.3 ̊ C; 100 F) are serious and *associated with bacterial and viral infection*

Major communication issues related to neurological disorders

1. Reception -Anxiety -Hearing deficits -Changes in cognition 2. Perception -Dementia -Delirium 3. Articulation -Mechanical difficulties -Resp disease -Larynx disorders

Learning & growing in late life is available in many formal & informal modes, including:

1. Self-teaching 2. College attendance 3. Participation in seminars, conferences 4. Public television programs 5. Videotapes 6. Courses via telecommunications/Internet

3 types of hearing of hearing loss

1. Sensorineural 2. Conductive 3. Tinnitus

Stages of AD - Alzheimer's dementia

1. Severe memory loss -ex: doesn't recognize own children 2. Other cognitive aspects: -Word-finding -Vision/spatial issues -Impaired reasoning/judgment 3. At this stage, individuals may: -Require full-time assistance with ADLs -Lose awareness of experiences and surroundings -Have changes in physical abilities (walking, sitting, eating/swallowing) -Have increased difficulty communicating -Become vulnerable to infections, especially pneumonia

6 difficult & sensitive subjects to assess

1. Sexual dysfunction 2. Depression 3. Incontinence 4. Alcoholism 5. Hearing loss -*people are reluctant to reveal that they have hearing loss bc again they feel their independence will be taken away* 6. Memory loss or confusion When assessing these difficult & sensitive subjects, *ask open ended questions at first & then more specific, closed-ended questions as you go* -also *assess person's willingness to talk* about these issues

Historically retirement was a few years of rest before death, now retirement is:

1. Transition to new life role 2. New jobs 3. Going part time 4. Traveling 5. Family 6. Some may be retired longer than worked full time

Sexuality in an older person is not about procreation. Emphasis shifts to:

1. companionship 2. physical nearness 3. intimate communication 4. physical pleasure-seeking relationship

Identification of abuse of older adults

1. cultural or societal tolerance of violence, especially against women 2. shame and embarrassment 3. fear of retaliation 4. fear of institutionalization 5. social isolation 6. unacceptability of emotion expression, especially that of fear or distress

CVA & sexual function

1. depression 2. may or may not have sexual activity changes 3. often erectile disorders occur 4. decreased physical endurance, fatigue 5. mobility & sensory deficits 6. perceptual & visual deficits 7. communication, cognitive & behavior deficits 8. fear of relapse or sudden death Interventions: 1. encourage counseling 2. instruct use of alternate positions 3. use pillows for support 4. suggest lubrication

Acute alcohol withdrawal is considered what?

A *life-threatening emergency* -Alcohol is the #1 drug in which withdrawal symptoms are fatal -Detoxification should *ALWAYS be done in an inpatient setting* (detox can result in cardiac arrest)

Home safety evaluation - problems & interventions for living room

1. soft, low chair: board under cushion, pillow/blanket to raise seat, blocks or platforms under legs, good armrests to push up on 2. swivel & rocking chairs: block motion 3. obstructing furniture: relocate or move to clear paths 4. extension cords: run along walls, eliminate unnecessary cords, place under sturdy furniture, use power strips with breakers

Volume overload 9 symptoms

1. weight gain >2% 2. I>O 3. bounding pulse 4. tachycardia, increased BP & CVP 5. distended neck/peripheral veins 6. crackles 7. dyspnea 8. SOB 9. confusion

Most severe alcohol abuse in older adults is seen in ages _____ to _____

60 to 80 Alcohol abuse is often a *coping mechanism in old age to deal with loss, anxiety, depression, chronic illness* -Alcohol use that is new in older adults is referred to as late onset drinking.

Fastest growing age group is ____ and older

85

Nonagenarian

90+ (ages 90-99)

TedEd q - Which of the following is the most common of the four ways to go? A. Frailty B. Sudden death C. Organ failure D. Terminal illness

A. Frailty

Person from minority or marginalized culture adopts that of dominant or majority culture

Acculturation

Precancerous skin lesion. Use sunscreen

Actinic keratosis (due to sun exposure)

_________________ is the leading cause of vision loss among people age 60 or older

Age-related macular degeneration -Affects the macula, the central part of the eye responsible for clear central vision -*causes progressive loss of central vision, leaving only peripheral vision intact* 2 types: 1. Dry (non-exudative) -*most common; 90% of cases* 2. Wet (exudative) -less common & most severe

Systematic stereotyping and discrimination against people because they are old

Ageism

Functional assessment - IADLs

Assesses person's ability to perform tasks for *independent living* -Needed to *maintain one's home* -*Tool: Lawton*

Frailty

Associations between age & chronic disease & the development of frailty remains in question The *formal diagnosis is made in the presence of at least 3 of the following:* 1. Unintentional weight loss 2. Self-reported exhaustion 3. Weak grip strength 4. Slow walking speed 5. Low activity *It's better to ask the patient about these symptoms. Many people consider the signs as just a normal part of aging*

Administration of meds via enteral feeding tubes

At high risk for medication errors -*most often occurs at the bedside, further increasing the risk of errors* -complications include occluded tube, reduced med effect, med toxicity, patient harm, & death.

Baby boomer

Born between 1946-1964 -3.4 million born in 1946 then 3-4 million every year through 1964 -began turning 65 in 2011 (around 72 years old right now)

Retirement is the expectation that an older person will:

Cease full time work and be entitled to economic assistance -Many people who are retired rely heavily on social security for financial support & medicare for healthcare needs

Thick, compacted skin. OTC preparations to remove, padding, avoid sharp tools.

Corns/calluses -Corn is a type of callus; gets a hard center piece in it & as the corn is pressed it causes lots of pain

The nurse over-hears a nursing assistant saying to an older client, "Good morning honey. Are we ready to take a bath?" How should the nurse respond? A. Interrupt and end the conversation. B. Report this behavior to the supervisor. C. Develop a unit communication seminar. D. Inform the worker of the observation.

D. Inform the worker of the observation.

Silver hour - death PCC goals

Declaration of death (brain or bodily death) 1. Available for support 2. Facilitate grieving 3. Follow wishes r/t death rituals 4. Allow family to say goodbye

__________ is an irreversible state that progresses over years in decline of intellectual function

Dementia -Dementia in relation to delirium is very different; dementia is *pathologic, meaning it results from changes in the brain that are irreversible.* Once the person enters dementia and starts progressing, they *do not ever return to a normal state.* With delirium, they do return to normal.

St. John's wort is used to treat:

Depression -mixed evidence 1. SEs: photosensitivity, rash, Gi upset, restlessness, anxiety, headache 2. Severe reactions: Mania, hypomania, suicidal/homicidal ideations 3. Contraindications: -Use with triptans, MAOIs, digoxin, antidepressants -*Overall, avoid in older adult* 4. Should be approved by healthcare provider 5. *Stop taking 5 days prior to surgery*

Social differentiation based on cultural criteria

Ethnicity

Belief that one's system is superior

Ethnocentrism

________ is a major complication of constipation. It's especially common in incapacitated & institutionalized older people & those who require narcotic medications.

Fecal impaction -*common in those who live in institutions & long term care facilities bc they may not be moving as much* Manifestations & complications: 1. Malaise 2. urinary retention 3. increased temp 4. incontinence 5. cognitive decline 6. hemorrhoids 7. intestinal obstruction *Paradoxical diarrhea, caused by leakage of fecal material around the impacted mass, may occur & cause person to think that they are having a BM.*

Yellow, brown nail. Flaking/erythema of skin of the feet. Most important intervention is to keep feet clean and dry.

Fungal infections

Permanently flexed toe. Custom shoes or surgery is the treatment.

Hammer toe

Bringing young & old together

Intergenerational Programs: 1. Older people assist younger people (tutoring, mentoring, child care, foster grandparent programs) 2. Younger people assist older people (social visits, meal assistance) 3. Younger and older people serve together

Some slowing of mental processing is:

NORMAL

Cognitive impairment is:

NOT NORMAL

_____________ are on the front lines during loss & death

Nurses -Must be able to respond properly to loss, dying, death, and grief & provide patient centered care during death/dying

Causes most of aging cosmetic problems. Most important intervention is to use sunscreen.

Photo damage

The use of many medications is called what?

Polypharmacy -20% 65 and older take 10+ meds -sometimes necessary for several co-morbidities, but often pts are prescribed meds for the same conditions -can result in adverse effects & drug interactions -*teach older patient to bring all meds in a bag to each visit with their healthcare provider*

________ is a person who has been legally appointed to act on behalf of another in ways that are specifically indicated in a legal document

Power of Attorney (POA)

Hyperkalemia 9 symptoms

Serum potassium > 5.0 mEq/L 1. diarrhea 2. cardiac dysrhythmias/arrest 3. ECG abnormalities 4. irritability 5. apathy 6. confusion 7. muscle weakness 8. areflexia 9. paresthesias

___________________ provides for *minimum level of economic support to persons 65+, blind or disabled regardless of earning power* in early life or when capable of working

Supplemental Security Income (SSI) -Either provides total support or supplements low Social Security benefit -In 2015, the supplementary security income provided for a max benefit of $733 a month for an eligible individual (1100 per couple) to provide for basic needs. -The determination of the total income the person has already includes the value of "gifts" such as housing. -The majority of the recipients are those older than age 65.

What is excretion?

The elimination of meds or their metabolites from the body -kidneys vastly responsible -GFR depends on both the rate & extent of protein binding of the medication; only unbound medications are filtered

____________ is a concept that incorporates ALL aspects of one's being

Wellness -more holistic view of a person's overall well-being & is the focus of nursing -wellness is expressed in functional, environmental, intellectual, psychological, spiritual, social, & biological dimensions of the human experience within the context of culture.

Most literature on aging focuses on which gender?

Women (there are more older women than men)

Pain clinics provide what?

specialized, comprehensive, and multidisciplinary approach to pain management that has not responded to standard approaches

Gerontological 4 nursing roles

*Gerontological nursing roles ARE nursing roles -- everyone is a gerontological nurse.* 1. Functions in variety of settings—hospital, home, subacute and long-term care facilities, community 2. Advanced practice gerontological nurses (don't really have this anymore - older adults receive care from FNPs) 3. *Mission is to preserve function, enhance health, and enhance quality of life and dying* 4. Gerontological nurses will play a significant role in research, innovations in care, and provision of services to the growing population of older adults in global society

Older population descriptions (6)

1. 3/4 of adults over age 65 suffer from at least one chronic medical condition (diabetes, HTN, high cholesterol, etc - many older adults have more than 1) 2. rely on health care services far more than other segments of the population 3. 42% of all older women are widowed 4. 39% women & 19% men live alone 5. educational levels are increasing 6. Poverty: in 2013, 9.5% below poverty level (4.2 million) & 5.6% at near-poor (2.5 million) -women 11.6% & men 6.8% -*highest poverty rates: older hispanic women who live alone (45.4%)*; this is because older hispanic women may have immigrated from another country, have no formal education, or because they are *highly focused on family throughout their lifetime & relied on spouse for income*

Non-opioid analgesics to promote comfort (4)

1. Acetaminophen -Maximum dose 4000mg in 24 hours from all sources -*Monitor renal and hepatic function* 2. NSAIDS -Safety alert: Aspirin and NSAID use -*When taken together decrease cardioprotective affect of aspirin* 3. Associated with significant number of adverse drug events in older adults -Nephrotoxic 4. Cox-2 inhibitors also have serious CV side effects

AD behavior concerns

1. Anxiety & depression 2. hallucinations (possibly) 3. delusions 4. aggression 5. screaming 6. restlessness 7. agitation 8. resistance to care

Stages of AD - Preclinical

1. Changes in brain are beginning to happen 2. No significant clinical sx 3. Amyloid building may be detectable with: -PET scan -CSF analysis

4 Hearing changes

1. Changes in cartilage of pinna 2. Decreased ceruminal glands in external ear 3. In middle ear, ossicle joint degeneration; tympanic membrane thinning & loss of resiliency -loss of vibration & transmission of sound 4. *In inner ear, atrophy of vestibular structures, cochlea, organ of Corti plus loss of hair cells*

Retirement implications - nursing responsibilities

1. Discuss retirement with clients (esp. in primary care) -Wouldn't be discussing retirement with someone in ICU; planning is mostly done with patients in primary care 2. Discuss transition to retired status 3. Health issues affecting retirement 4. Resources for planning and support

What 3 herbs or supplements should be stopped at least 2 weeks before surgery?

1. Garlic 2. Ginkgo 3. Ginseng

Culturally sensitive assessment (7)

1. How would you describe the problem that has brought you here? 2. How long have you had this problem? 3. What do you think is wrong with you? 4. Why do you think this happened to you? 5. What are the chief problems your sickness has caused you? 6. What do you think will help this problem? 7. Apart from me, who else do you think can make you feel better?

Programmed aging includes what 2 theories?

1. Neuroendocrine control/pacemaker theory -explains aging as programmed *decline in the functioning of the immune, nervous, & endocrine* systems -"replicative senescence"- *cells lose their ability to reproduce* 2. Immunity theory -aging is programmed *accumulation of damage and decline in the function of the immune system* ("immunosenescence") -damage is a *result of oxidative stress* -*t-cells thought to be responsible* for increasing age-related auto-immune disorders

Adverse drug reactions (6)

1. Not just a SE; occur where there is a noxious response to med 2. can occur from one drug or from 2 or more drugs together (2 CNS depressants, 2 antihypertensives) 3. reactions causing or potentially causing harm 4. sometimes predictable; can be proactive, such as preventing infection in those on immunosuppressants 5. sometimes unpredictable -allergic reactions, bleeding risks 6. often overlooked in older adults

Interventions to enhance vision

1. Use contrasting colors -Black and white -*Reds and oranges easiest to see* 2. Assistive devices -Image magnification -Text-to-speech scanners -Tablets 3. General -Closer to objects -Large font

How to communicate with a person experiencing delirium

1. know persons past patterns 2. look at nonverbal signs 3. speak slowly 4. be calm and patient 5. face the person and keep eye contact, smile 6. use simple, familiar words 7. allow adequate time for response 8. repeat if needed 9. tell person what you want from them rather than what you do not want 10. give one step directions; use gestures and demonstrations 11. reassure of safety 12. keep caregivers consistent 13. assume communication and behavior are meaningful 14. do not assume that person is unable to understand

Dehydration 11 symptoms

1. orthostatic hypotension 2. weight loss 3. tachycardia 4. hyperthermia 5. weakness 6. nausea 7. anorexia 8. oliguria 9. dry mucus membranes & skin 10. poor skin turgor 11. increased thirst

Centenarian

100+ -97k now, 601k by 2050 -- *calling this a gerontological explosion* -most are female (85%) -30% have NO evidence of dementia; *the older adult 100+ must be extremely hardy & healthy to have lived this long*

Older adults account for ____% of the population, but ____% of suicide deaths

13% of population; 20% of suicide deaths -higher than any other age group -*older widowers are most vulnerable & have the highest risk of suicide* in the older adult population; *men in general have HIGHER suicide rates* *Up to 75% of older adults who die from suicide visited physician within one month of death* -why depression screenings are important for all older adults; *medicare requires older adults be screened for depression every time they visit their HCP* -assess for warning signs & risk factors for suicide

______% of older people experience constipation & is more common in _______

40%; more common in women Constipation is a reduction in bowel movement frequency or difficulty in forming or passing of stool

Behavior and psychological symptoms of dementia (BPSD) - nursing care

*All behavioral and psychological symptoms of dementia are meaningful and expression of need* 1. First rule out medical problems -Infection, dehydration, pain, fractures, impaction -GI/GU problems cause much distress 2. Consider psychosocial problems -Fear, discomfort, unfamiliar things, fatigue, depression, loss of control/autonomy, etc -May misinterpret stimuli

________ intelligence DECREASES while ________ intelligence remains stable

*Fluid decreases; crystallized remains stable* -related to speed of cognitive processing and slower reaction time

OLDCART - pain assessment

*O*nset *L*ocation *D*uration *C*haracteristics *A*ggravating factors *R*elieving factors *T*reatment previously tried

When a person has acute decompensated HF (HF exacerbation), they come into ER swollen & unable to breathe. What is the most important intervention for this person?

*REMOVING THE FLUID.* If the person is having pulmonary edema & you give them O2, not much will happen because there is fluid in the alveoli & air can't reach it. Therefore, *removing fluid with something like a diuretic is the most important intervention*

If you suspect that a person is having trouble with eating or swallowing during a meal or drinking, what's the most important thing to do?

*STOP FEEDING THEM OR GIVING FLUIDS*. Do not continue to give them fluid & feed them bc this can lead to a complication such as pneumonia

Clock drawing test (CDT)

*Screens AND diagnoses dementia* -not for mild cognitive impairment -*Manual dexterity and visual acuity required* (not appropriate for blind, Parkinson's disease, stroke, severe arthritis - *can result in a false positive*) Directions: -provide white plain paper with circle drawn on it, 5 in diameter -ask person to draw numbers in the circle so that it looks like a clock and then put hands to read "10 after 11" Scoring: -*score of 1 or 2 is considered normal* -*score of > 3 represents a cognitive deficit.*

Treatment for thyroid storm (6)

*WOULD NOT GIVE THYROID HORMONE.* 1. Need to cool pt down with ice 2. Reduce levels of TH (might be giving them tapazole) 3. Replace fluids & electrolytes 4. Give O2 5. Stabilize cardiac function 6. *AVOID ASPIRIN - increases thyroid hormone*, so *would not give this during a thyroid storm to decrease temp*

Assessment of need includes use of strategic questions to obtain health history

1. "Do you have a romantic partner?" not "Do you have a boyfriend/girlfriend or married?" 2. "How do you identify with regard to your sexuality?" 3. Don't assume heterosexuality

11 nursing actions families report as helpful

1. "They kept me informed." 2. "Asked how I was doing and offered support." 3. "Put their arm around me when I cried." 4. "Brought me food" 5. "Knew my name." 6. "Cried with me" 7. "Brought me a bed and encouraged me to stay in the room while he was dying." 8. "Told me to hold his hand" 9. "Held my hand" 10. "Got the Chaplain for me." 11. "Let me take care of my husband."

Hyperthyroidism 5 nursing diagnoses

1. (risk for) Decreased cardiac output r/t increased metabolic and oxygen demands or dysrhythmias or elevated BP 2. Disturbed sensory perception r/t corneal dryness or difficulty focusing 3. Imbalanced nutrition: Less than body requirements r/t hypermetabolic state and increased gastric motility 4. Disturbed body image r/t physical changes from disease process - manifestations of hyperthyroidism like exophthalamus 5. Anxiety r/t effects of elevated thyroid hormone

Cultural variations & abuse - Japanese

1. *80% report psych abuse is worst* 2. emotional abuse, neglect, physical abuse reported to be *perpetrated by daughters-in-law* 3. lack of caring for elder is a *sign of disrespect and socially unacceptable* 4. *suffering is expected to be done in a stoic manner* 5. fatalism to suffering, should it occur 6. self-blame 7. those who expose a family "shame" may be considered a traitor

Nursing interventions for elder abuse

1. *Prevent the abuse from continuing* 2. Licensed nurses are considered mandatory reporters—required to report suspicions of elder abuse to Adult Protective Services -if under the age of 18, must be reported -*if between the ages of 18-64, it's not required to report. Social services can only be called if you have permission* -*if the person is 65 or older, same rules as it is with a child - must be reported.* 3. Reasonable belief that a vulnerable person has, is, or likely to be abused, neglected, or exploited

3 characteristics of older adults that influence ability to manage and cope with stress

1. *Resilience: flourishing despite adversity* -Successfully adapting to difficult and life challenging experiences -Positive interpersonal relationships -High self-esteem and self-efficacy -Sense of purpose -Creativity and sense of humor 2. *Hardiness: Control, commitment & challenge* -Stress is a challenge and opportunity for growth -Social connectedness -Confronting problems head-on -Extending oneself to others -Spiritual grounding 3. *Resourcefulness: Toolbox of self-control skills & belief that the tools may be used effectively* -Self-control -Self-direction -Self-efficacy

-giline client teaching (5)

1. *Take at same time each day* 2. Report insomnia 3. Interventions to prevent postural hypotension 4. Skin exams - *risk of melanoma* 5. *Avoid foods containing tyramine*: aged cheeses, wine, dark chocolate

Suicide assessment

1. ANY reference to ending life must be taken seriously 2. Establish trusting and respectful relationship 3. Behavioral cues - goodbyes, giving away possessions -have to be careful about looking at older adults giving away possessions as a sign of potential suicide - its normal for older adults to give things away bc they say they "have too much stuff" -it is *NOT normal if they have had an event in their life, such as losing a spouse, and they become more withdrawn and give everything away except for the departed spouses belongings.* THIS is a sign of potential suicide

GI assessment (6)

1. Assess abdomen (note smaller liver), bowel sounds -will be able to feel smaller liver if they are thinner; may be unable to palpate -bowel sounds will be reduced 2. Monitor weight, dietary intake, elimination patterns -monitor fluid volume, how often they go to the bathroom -always compare elimination pattern to baseline -may see a decrease in BM frequency 3. Assess dentition, chewing & swallowing abilities, eating habits/nutrition -tooth decay is common; can cause a decrease in eating 4. Assess pulmonary infection from aspiration/dysphagia 5. Presence of NVD -*monitor CLOSELY bc older adults can quickly become dehydrated & be an emergency* 6. Evaluate chemosensory complaints of poor food taste

Endocrine assessment (2)

1. Assess functionality, fall risk, hydration (fluid intake/output), BP (orthostatic) 2. Monitor lab values (ex: fasting & post-prandial blood sugars; bone mineral density DEXA)

Musculoskeletal assessment (2)

1. Assess functionality, mobility, fine & gross motor skills, ADLs 2. Ensure joint stabilization and slow movements in ROM exam to prevent injury

Hearing assessment (4)

1. Assess hearing, balance & equilibrium 2. Inspect ear for cerumen build-up; remove if impacted 3. Monitor psychosocial dysfunction if hearing loss -loss of hearing can lead to social isolation 4. Evaluate safety of home environment, driving

4 factors influencing mental health care

1. Attitudes and Beliefs -Stigma: *older generations experience a more negative stigma regarding mental health* than younger people -*Myth that mental health disorders are normal with aging* 2. Availability and Adequacy of Mental Health Care -Access -Ability to pay: older adults often have medicare, which is not great for covering mental health care 3. Care Settings -Place of treatment -Who is providing care/staffing: *lack of proper training to therapeutically communicate with patients* 4. Cultural and Ethnic Disparities -Poverty -Language -Cultural understanding: one culture might see mental health problems as a punishment from god, so understanding the culture of the individual is essential when caring for them

Spiritual nursing responses - nurses can promote physical comfort by:

1. Bathing 2. Positioning 3. Pain and symptom relief 4. Touch 5. Peaceful environment Physical needs must first be met so that the person can progress to a spiritual state of mind or use their spirituality for healing -*physical needs before psychosocial*

Malignant syndrome (2)

1. Bc antipsychotics affect the thermoregulatory pathway, patients taking them can't tolerate excess environmental heat -*mild elevations of core temp can result in liver damage (NMS) & heat stroke* -acute NMS is characterized by *high fever, rigidity, altered mental status, tachycardia, & pallor* 2. *Assess temp regularly. Keep pt hydrated, cool baths, fans*

Guide for working with interpreters

1. Before an interview or session with a client, meet with interpreter to explain the purpose of the session, instruct interpreter to use person's own words, instruct the interpreter to avoid inserting his or her own ideas or omitting any info 2. look and speak directly to the client, not the interpreter 3. be patient; interpreted interviews take more time 4. use short units of speech 5. use simple language; avoid medical jargon 6. listen to client & watch nonverbal communication to learn about emotions regarding a specific topic 7. clarify the clients understanding and accuracy of the interpretation by asking client to tell you in his or her own words what he or she understands, facilitated by the interpreter

6 needs of the dying - 6 c's approach

1. Care 2. control 3. composure 4. communication 5. continuity 6. closure

Biological theories of aging

1. Cellular functioning: Survival of an an organism *depends on successful cellular reproduction* (mitosis) -cells replicate, but not exactly the same. They become more complex/specific over time -*with increased replication, there's increased accumulation of damage* 2. Programmed aging theories 3. Error theories

Hearing changes 4 CM

1. Changes in external ear appearance (larger, longer) 2. Drier cerumen with risk of impaction & hearing loss -*decreased production of ear wax; ear wax that is produced is thicker & can become compacted* 3. Decreased sound conduction 4. Risk of hearing loss (initially of high pitches; presbycusis - age related hearing loss), tinnitus, equilibrium-balance deficits -inner ear is responsible for balance; fluid build up can cause dizziness & puts pt at higher risk for falls

Cataract manifestations

1. Clouding of lens 2. Absent red reflex or appear black 3. Appearance of halos *around objects* (rather than around lights like with glaucoma) 4. Blurred vision 5. Yellow tint to vision 6. Sensitivity to glare

3 non-pharmacological interventions for anxiety

1. Cognitive behavioral therapy (CBT) 2. Meditation 3. Yoga *Medication treatment should be done in addition to therapy; CBT has the best results* *Therapeutic relationship between patient and health care provider is the foundation for any intervention*

OP diagnosis & screening

1. Diagnosed with a *DEXA scan* (scan that measures bone density). 2. The *result is in a T-score* -*osteopenia: diagnosis -1 to -2.5* -*osteoporosis: diagnosis if less than -2.5 (higher the absolute number, the worse the OP is)* 3. The U.S preventative services task force (USPSTF) is working on new recommendations for screening for OP. *The major recommendation now is that all women over 65 should be screened* -men can also develop OP but there is not a general screening guideline. Many HCPs will still screen them, but have a lot more trouble getting insurance to pay for it

Eye changes 4 nursing interventions

1. Educate on regular eye exams 2. Driving hazards due to visual impairments -teach pt to drive during the day & avoid driving at night 3. Organize house - fall prevention, safety, adequate lighting 4. Appropriate use of colors -*Older adults see colors that are red, yellow, & orange better than blue & green* -reason why there are more red colors in nursing homes in attempt to decrease falls

Endocrine changes 2 nursing interventions

1. Education on nutrition (especially calcium & carbs), hydration, safety 2. Onset of diabetes & thyroid alterations

9 Non-pharmacologic measures to promote comfort

1. Energy/Touch Therapies 2. Transcutaneous Electrical Nerve Stimulation (TENS) 3. Acupuncture and Acupressure 4. Relaxation, Meditation, and Guided Imagery 6. Music 7. Hypnosis 8. Activity 9. Cognitive-Behavioral Therapy

Anxiety disorders in older adults are associated with: (5)

1. Excessive healthcare use 2. Decreased physical activity and functional status 3. Substance abuse 4. Decreased life satisfaction 5. Increased mortality rates

Special considerations for caregiving in MCI, early-stage, & early onset dementia

1. Focus on communication, behavior, and relationships 2. *Individuals are aware of their diagnosis* and need support to share their feelings and needs 3. Caregivers need support to deal with changing role, changing couple relationships, anger, frustration, uncertainty about the future, burden, and depression

AD - person-centered care

1. Foster abilities 2. Support limitations 3. Ensure safety 4. Enhance QOL 5. Prevent disability 6. Maintain function 7. Structured environment 8. Promote relationships

10 predictors of retirement satisfaction

1. Good health 2. Functional abilities 3. Adequate income 4. Suitable living environment 5. Strong social support system characterized by reciprocal relationships 6. Decision to retire involved choice, autonomy, adequate preparation, higher status job before retirement 7. Retirement activities that offer an opportunity to feel useful, learn, grow, and enjoy oneself 8. Positive outlook, sense of mastery, resilience, resourcefulness 9. Good marital or partner relationship 10. Sharing similar interests to spouse/significant other

Musculoskeletal changes 11 CM

1. Great variability in changes among individuals 2. Kyphosis, Height loss (1-4") -*loss of height largely due to osteoporosis; results from compression of spine* 3. Gait & balance instability common 4. Risk of osteoporosis & fractures, osteoarthritis 5. Reduced extremity fat; truncal obesity 6. Decreased total body water & intercellular/interstitial fluid 7. Risk of fluid/electrolyte imbalances 8. Decreased muscle strength & agility; slowed deep tendon reflexes/reaction times 9. Decreased endurance 10. Joint stiffness with decreased mobility 11. Risk of injury, joint subluxation, crepitus & pain on ROM

Retirement prep is largely aimed at those with:

1. High education 2. High occupational status 3. Gov't employees 4. Employed in companies with pensions

7 Risk factors for hypothermia

1. Impaired circulation 2. Diabetes 3. Adrenal or thyroid dysfunction 4. Malnutrition 5. Excessive alcohol use 6. Inadequate housing or supervision 7. Use of sedatives, anxiolytics, antidepressants

Social factors influencing the grieving process

1. Individual support systems & the acceptance of assistance of its members 2. Individual sociocultural, ethnic, religious, or philosophic background 3. Educational, economic, & occupational status 4. Ritual

Adult cognition 7 components

1. Language 2. Thought 3. Memory 4. Executive function -Organization: gather info -Regulation: evaluate & change behavior 5. Judgment 6. Attention 7. Perception

Respiratory changes 5 nursing interventions

1. Maintain patent airway through repositioning (raise HOB, semi-fowlers), suctioning 2. Prevention of respiratory infections 3. *Incentive spirometry/Pursed-lip breathing (keeps airway open to expel CO2)* 4. Flu & pneumonia vaccines -*should be getting pneumonia vaccines starting at 60* 5. Education on cough enhancement, avoidance of environmental contaminants, smoking cessation

6 key points of chronic illness trajectory framework

1. Majority of health problems in late life are *chronic* 2. Chronic illnesses may be lifelong and entail lifetime adaptations -Profoundly affect lives/identities of individual and family/caregivers 3. Acute phase of illness management is designed to *stabilize physiological processes and promote recovery* from acute phase 4. Other phases of management are designed to *maximize and extend period of stability in home* with help from family; augmented by visits to and from health care providers 5. *Maintaining stable phases is central in managing chronic illness* 6. Primary care nurse is the coordinator of multiple resources needed to promote quality of life along the trajectory

Aphasia communication strategies

1. Make sure you have the person's attention before you start. 2. Minimize or eliminate background noise (TV, radio, other people). 3. Keep your own voice at a normal level, unless the person has indicated otherwise. 4. Keep communication simple, but adult. Simplify your own sentence structure and reduce your rate of speech. Emphasize key words. Don't "talk down" to the person with aphasia. 5. Give them time to speak. Resist the urge to finish sentences or offer words. 6. Communicate with drawings, gestures, writing and facial expressions in addition to speech. 7. Confirm that you are communicating successfully with "yes" and "no" questions. 8. Praise all attempts to speak and downplay any errors. Avoid insisting that each word be produced perfectly.

Examples of legacies

1. Oral histories 2. Autobiographies 3. Shared memories 4. Taught skills 5. Works of art, music 6. Publications 7. Human organ donations 8. Endowments 9. Objects of significance 10. Written histories 11. Tangible or intangible assets 12. Personal characteristics such as courage or integrity 13. Bestowed talents 14. Traditions and myths perpetuated 15. Philanthropical causes 16. Progeny children and grandchildren 17, Methods of coping with aging and toward death 18. Unique thought: Darwin, Einstein, Freud, (Thought patterns established based on their concepts & theories)

Pain & comfort

1. Pain management - a patient right 2. "5th vital sign" 3. A key nursing quality indicator in acute care and nursing home setting 4. *Undertreated in older adults, especially in elders of color and cognitively impaired adults* -language & cultural heritage affect a patient's willingness to express the manifestations of pain

Skin changes 4 nursing interventions

1. Prevent pressure ulcers 2. Educate on care of dry, fragile skin 3. Maintain environmental temperature control to prevent hypo/hyperthermia 4. Provide adequate fluid intake to prevent dehydration

OP 5 interventions

1. Promotion of bone health begins in teen years -major intervention for OP 2. Weight loss can help - One pound of weight places FOUR pounds of force on the knees! 3. Weight bearing and resistance training 4. *Adequate calcium and vitamin D intake* 5. *Education about fall prevention*

5 Nursing implications for herbs & supplements

1. Proper assessment of herbs and supplements 2. Inform clients of benefits and harms 3. Manufacturing -No standardization -Where to obtain quality agents 4. Assess for SEs, interactions, urge to stop if any issues, and talk to HCP 5. *Recommending H&S is a prescriptive action* -Stay within your scope, even when making informal recommendations

AD nursing intervention care

1. Psychotropic medications -*NOT recommended as first line* -Nurses and providers still use too often -*SEs are detrimental: etxrapyridimal signs, orthostasis, somnolence, neuroleptic malignant syndrome* -More understanding and interdisciplinary care needed 2. Non-pharm interventions -More effective and improve QOL -Activities, therapies, exercise, sensory stim, reminiscence, environmental design, staffing, lighting, relaxation, distraction, non-confrontational approaches 3. Bathing -Can potentiate distressing behaviors -*Explain actions every time you bathe the person* -Don't push; need to be slow & gentle -Provide positive feedback & demonstration -Encourage self-care

Factors changing the demographics of older people

1. Race and ethnicity 2. Gender -race, ethnicity, & gender are all based on genetics; *genetics plays a big role in how long a person will live* 3. Marital status: people who are married or in committed long-term relationships tend to live longer 4. Living arrangements: those who are part of a family unit as they age tend to live longer 5. Economic status: those with a higher economic status live longer

GU changes 11 CM

1. Risk of renal complications in illness; susceptibility to acute ischemic renal failure & embolism 2. Risk of dehydration, volume overload, *hyperkalemia (with potassium-sparing diuretics), hyponatremia (with thiazide diuretics), hypernatremia (with NSAIDs)* 3. Reduced excretion of acid load 4. Risk of postural hypotension 5. Decreased drug clearance 6. Risk of nephrotoxic injury by drugs -*NSAIDs are highly nephrotoxic, want to avoid in elderly* 7. Normal renal function: constant serum creatinine level; absent proteinuria 8. Risk of urinary tract infection (UTI) bc of increased post-void residual urine 9. Nocturnal polyuria- *risk for falls* 10. In males, risk of urinary hesitancy dribbling, frequency, incontinence bc of BPH -*how to measure post void residual with retention/BPH: ask last time pt voided, perform a catheterization, palpate the abdomen* -*best way to measure is by using a bladder scan bc it's noninvasive* 11. In females, risk of atrophic vaginitis, urethritis, vaginal stenosis, vaginal/uterine prolapse

6 Psychosocial theories

1. Role -*successful aging = adapting to changing roles* -resistance may predict poor adjustment 2. Activity -*successful aging = maintaining a productive life (physically & mentally)*; maintain involvement in activities/hobbies that they have enjoyed all their life 3. Disengagement -*successful aging = transfer control to younger generation* -society distances itself from the older adult and the older adult disengages from society -now considered controversial 4. Continuity -*successful aging = maintain & continue previous behaviors & roles or find replacements* 5. Age-stratification -*individuals of similar age (cohorts) have most similarities* -for example, baby boomers age similarly to other baby boomers 6. Modernization -*older people lose power & status due to advances in technology, etc.* -widely challenged because older adults CAN learn new technologies, while others can feel left behind

Cardiovascular changes 3 nursing interventions

1. SAFETY - institute *fall precautions* for orthostatic hypotension; rise slowly from lying or sitting position -monitor for *overt signs of hypotension: change in sensorium/mental status, dizziness* 2. weight is an indication for fluid volume -*if pt has gained 2 pounds, they have retained a liter of fluid* 3. Ensure pt is taking meds as prescribed; take appropriate vitals before administering

Urinary incontinence 6 interventions

1. Scheduled & Prompted voiding -scheduled voiding: tell person to go every 2-3 hrs whether they feel like or not -prompted voiding: remind person to go 2. Pelvic floor muscle exercises (kegels) -increases tone of the muscles that hold urine in the bladder 3. Thorough assessment of continence -how long has it been going on, when did it start, is it happening during the day or at night -*asking these questions helps to identify whether it is new onset & could be a UTI* 4. Lifestyle Modifications -Avoid caffeine (not much evidence), smoking cessation, bowel mgmt, healthy weight, exercise 5. Medications -*Most have anticholinergic effects & cause urinary retention* -also have meds that can decrease the spasms of the bladder 6. *Urinary catheters = last resort*

Residential care options in later life

1. Shared housing with family members or others 2. Community care -Program for All-Inclusive Care for the Elderly (PACE): comprehensive continuum of care by interdisciplinary team; includes primary care, acute care, nursing home care, & specialty care -Adult Day Services -Residential care facilities -Continuing care retirement communities 3. Skilled Nursing Facilities -Skilled nursing care (sub-acute) -Chronic care (long-term/custodial) -Offer 24/hour care for those needing specialized nursing care

Feet age-related changes (5)

1. Skin becomes drier, less elastic, cooler bc they are less well-perfused 2. Subcutaneous tissue on dorsum (top of foot) and sides of foot thins 3. Plantar fat pad (bottom of foot) shrinks and degenerates 4. Toenails become brittle, thicken, *less resistant to fungal infections* 5. Degenerative joint disease decreases ROM

Pain scales (3)

1. Standard of care in pain assessment 2. Multiple pain scales available for cognitively INTACT older adults (0-10) 3. Cognitively impaired non-verbal adults require close assessment of cues & behaviors to evaluate presence of pain -PAINAD: pain assessment in advanced dementia -PACSLAC: pain assessment checklist for seniors with limited ability to communicate

Drug-supplement interactions (4)

1. Supplements are often underreported 2. becoming more popular to take 3. though often effective - there are issues -St. John's wart (for depression) *decreases digoxin levels* -Ginkgo biloba (for memory) *causes a false elevation of INR* -*warfarin may also be decreased, increasing the risk for clotting* 4. Supplements are NOT regulated by the FDA & not labeled well with interaction risks

Proper foot care

1. Teach pt importance of yearly foot exam by HCP - especially if the patient has diabetes 2. Care of toenails -*best cut after soaking for 20-30 min* -clip straight across, not at a curve. *Clipping at a curve can cause infections & ingrown toenails* 3. Wear proper fitting footwear 4. Wear orthotic shoes as needed

Levodopa, carbidopa, & amantadine client education (6)

1. Teach pt that medications *DO NOT WORK IMMEDIATELY.* Takes weeks or months to take effect 2. Avoid high protein diet: *high protein diet decreases function of meds* 3. *Avoid foods with pyridoxine* -*pork, beef, avocado, beans, & oatmeal* -will react with the dopamine precursors 4. Side effect of these meds is increased acid in the stomach causing reflux & heartburn; use antiemetics & PPIs/H2 receptor antagonists PRN 5. Interventions to decrease postural hypotension 6. Teach to *report increased symptoms & cardiac side effects* -any CV symptoms MUST be reported bc these meds increase the risk of CV events

Who is at risk for poor retirement planning?

1. Those with poor health 2. Minorities 3. Women 4. Lower socioeconomic status 5. Lower education *retirement prep is often lower priority for these people*

Prevention of adverse drug reactions (4)

1. Understanding of pharmacokinetics and dynamics in older 2. Lower dosages of some meds 3. "Start low, go slow, but go." 4. Contraindicated meds in older (risk of falls)

Emotional factors influencing the grieving process

1. Unique nature & meaning of loss 2. Individual coping behavior, personality, & mental health 3. Individual level of maturity & intelligence 4. Previous experience with loss or death 5. Social, cultural, ethnic, religious, or philosophic background 6. Sex-role conditioning 7. Immediate circumstances surrounding loss 8. Timeliness of the loss 9. Perception of preventability (sudden vs expected) 10. Perceived importance of the loss or relationship to that which is lost 11. Number, type, & quality of secondary losses 12. Presence of concurrent stresses or crises

Mood stabilizers

1. Used for bipolar disorder & psychosis r/t dementia 2. *Valproic acid (depakote) & lamotrigine* -*anticonvulsants used as mood stabilizers; better than lithium* 3. Lithium -older med -not used as often now -lots of drug drug interactions & SEs -*if person has been taking for a long period of time & it has been effective, leave them on it*

What is old? (7)

1. WHO - 50 yrs 2. United Nations - 60+ 3. *Western countries - 65+ yrs* 4. Young-old: 65-74 yo 5. Middle-old: 75-84 yo 6. Old-old: 85+ yo 7. Elite-old: 100+ yo *Older adults defined in the U.S. as someone 65 & older*

Error theories include what? (3)

1. Wear and tear 2. cross linkage 3. oxidative stress/free radical theories

HTN 5 interventions

1. Weight reduction (decrease of 5-20 mmHg per 10 lb weight loss) -need to be careful with older adult losing weight; they can become malnourished 2. Adopt DASH diet (decrease of 8-14 mmHg) -low sodium, low calorie, low fat 3. Lower sodium intake (decrease of 2-8 mmHg) 4. Increase physical activity (decrease of 4-9 mmHg) 5. Alcohol in moderation (decrease of 2-4 mmHg) *#1 thing to do to lower BP is to LOSE WEIGHT.* -All of these interventions need to be bundled together in order to effectively lower BP. Person can't just lower sodium intake & expect major changes

7 indicators of an appropriate & good death

1. care needed is received, & it is timely & expert 2. one is able to control one's life & environment to the extent that is desired & possible & in a way that is culturally consistent with one's past life 3. one is able to maintain composure when necessary & to the extent desired 4. One is able to initiate & maintain communication with significant others for as long as possible 5. life continues as normal as possible while dying with the added tasks that may be needed to deal with & adjust to the inevitable death 6. one can maintain desirable hope at all times 7. one is able to reach a sense of closure in a way that is culturally consistent with one's practices & life patterns

Examples of causes of neglect by caregivers

1. caregiver personal stress and exhaustion 2. multiple role demands 3. caregiver incompetence 4. unawareness of importance of the neglected care 5. financial burden of caregiving limiting resources available 6. caregivers own frailty and advanced age 7. unawareness of community resources available for support and respite

13 risk factors for depression in older adults

1. chronic medical illnesses, disability, and functional decline 2. alzheimer's and other dementias 3. bereavement 4. caregiving 5. *female (2:1 risk)* 6. socioeconomic deprivation 7. family history of depression 8. previous episode of depression 9. admission to long-term care or other change in environment 10. meds 11. alcohol or substance abuse 12. living alone 13. widowhood

UTI symptoms

1. dysuria 2. flank or suprapubic pain 3. hematuria 4. urinary frequency/urgency 5. cloudy/malodorous urine 6. anorexia 7. confusion 8. nocturia 9. enuresis (involuntary urination)

GI changes 2 nursing interventions

1. educate on nutrition/diet, approaches to flavor enhancement, fluid intake, toileting habits/bowel training -teach person to not to use too much salt 2. watch hidden sodium in foods -watch for packaged meats; teach how to read labels -*people will think they are doing better by using salt substitutes but they contain a TON of potassium & can result in hyperkalemia*

Who is more likely to abuse or neglect an older adult?

1. family member 2. one with emotional or mental illnesses 3. one who is abusing alcohol or other substances 4. history of family violence 5. caregiver frustration 6. social isolation 7. impaired impulse control of caregiver

3 consequences of inappropriate assessment

1. increased morbidity & mortality 2. missed diagnosis -may think that someone is confused just because they are older, but this could actually indicate an infection 3. unnecessary use of emergency rooms

What places an older client at risk for polypharmacy?

1. lack of communication between providers 2. living in a long-term care facility 3. having a disability 4. multiple specialty healthcare providers

Home safety evaluation - problems & interventions for home management

1. laundry: easy to access, sit on stool, good lighting, fold laundry sitting at table, carry laundry in bag on stairs, use cart, use laundry service 2. mail: easy to access mailbox, mail basket on door

Skin assessment (4)

1. monitor skin temp, turgor -*assess skin turgor on chest and forehead - hand is not a good indicator of turgor bc of looser skin* 2. Inspect for changes in skin color, pigmentation, lesions, bruising 3. Assess intertriginous areas (skin folds - areas skin touches skin such as groin, under breasts; contain more moisture leading to a higher risk of infection, specifically fungal) 4. Assess hygiene; need for podiatry services

Cultural variations & abuse - Chinese

1. must be kept in family 2. *disrespect most important form of mistreatment* 3. cultural disparities in expectations between younger and older adults

Herbs & supplements - standards in manufacturing

1. overall considered dietary supplements -much less scrutiny than meds 2. Manufactures may not say that herbs & supplements: prevent disease, treat disease, or cure a disease -however, most think & believe this 3. Differences in manufacturing -small businesses making H&S in small labs with no regulation -some conduct scientific research to evaluate efficacy -often with lots of fillers - soybeans, rice, yeast 4. FDA approves only a few -aloe, psyllium, capsicum, witch hazel, cascara, senna, and slippery elm -those non-FDA approved may still have positive benefits

_____ of adults 65 and older are obese

1/3. -Recently seen sharp rise in obese or overweight older adults Obesity paradox: some research has found that *being overweight might be protective in those who are 70 or older* -Does not mean to tell older adults to gain weight, but we notice that people who are 70 or older and mildly obese tend to live longer. -If the person is below the age of 70 & obese, they do not live longer Healthy weight throughout life is intervention best supported by evidence. So if a person has been a normal weight throughout their whole life & gains a few pounds at 75 we're not worried about it.

Based on census reports of 2010, the typical profile of a centenarian in the U.S. includes which of the following characteristics?

A caucasian woman who lives in an urban area of a Southern state

Acute vs. chronic illness

Acute illness -occurs suddenly & often without warning -stroke, MI, hip fracture, infection -acute illnesses can potentially cause chronic problems, comorbidities, & even death. Chronic illness -person will never get rid of & will have for the rest of their life -managed rather than cured, such as diabetes. Person can make lifestyle changes & get their A1C down without meds, but still consider them having diabetes. -chronic illness is always present but not always visible -degree in which it can be treated varies

Error theories

Aging is the result of an accumulation of random *errors in the synthesis of cellular DNA & RNA* -*non-predictable*

Primary prevention strategies for older adults include which of the following?

An annual immunization & brisk walking 3 to 4 times a week

Fall risk assessment

Assessment tools: 1. Hendrich II Fall Risk Model 2. Morse Fall Scale 3. Minimum Data Set (MDS 3.0) Major risk factors: 1. Orthostatic hypotension 2. Cognitive impairment 3. Impaired vision and hearing 4. Medications 5. Environmental factors 6. Weakness and frailty

A 76 year old client tells the nurse that they stopped their citalopram (Celexa) because of sexual side effects. What complications should the nurse anticipate? A. sleepiness and headache B. headache and anxiety C. elevated liver and kidney function tests D. mania and fluid retention

B. headache and anxiety

A _____________ is an opacity in the lens causing the lens to lose transparency or scatter light

Cataract -caused by *oxidative damage to lens protein & fatty deposits* in the ocular lens -by age 80, more than half have a cataract -*usually bilateral*

____________ and _____________ are most likely to lose vision from age-related macular degeneration

Caucasians & Asians Risk factors for macular degeneration: 1. UV light 2. Cigarette smoking -*from external exposure of smoke on the eye*, not systemic 3. Light-colored eyes

The most important capacity in humans is:

Communication *Inability to communicate = dehumanizing* Need to: communicate, be listened to, and be heard; *this does NOT change with age or impairment* Meaningful communication and engagement results in: 1. Healthy aging 2. Prolongs lifespan 3. Better response to healthcare interventions 4. Maintenance of optimal function Good communication is the basis for: 1. Accurate assessment 2. Care planning 3. Development of therapeutic relationships between nurse and older person

PD 4 complications

Complications in late stages can be fatal 1. Pressure ulcers -results from reduced mobility 2. Pneumonia 3. Aspiration -*Motor dysfunction causes the muscles to be affected, which can lead to difficulty swallowing --> aspiration --> pneumonia* 4. Falls

The development of cultural proficiency with increased awareness of our own beliefs and attitudes and those commonly seen in the community of health care

Cultural awareness

__________ is a reduction in total body water

Dehydration -A geriatric syndrome Dehydration in older adults is *often due to a disease process*: DM, HF, respiratory disease, frailty -treatment for HF is fluid restriction so person may only be allowed 1 L per day Complications: 1. Delirium -can occur very easily bc of dehydration 2. Thromboembolism (clot) 3. Infection 4. Renal failure 5. Kidney stones 6. Constipation 65-74 yo: 63% don't get enough fluid 75-84 yo: 73% 85+ yo: 81%

___________ is the most common mental health problem of late life

Depression 1. not a normal part of aging 2. 1/10 older adults visiting a physician suffers from depression 3. *depression & physiologic illness are likely to co-occur*. For instance, if the older adult has HF or diabetes, there's a high risk of the person developing depression bc they have a lot of physical limitations, fear of death, etc. 4. *depression can result from side effects of medications:* ACEIs, beta blockers, antidysrhythmics, antibiotics -*beta blockers have more depressive SEs than ACEIs; especially the older beta blockers like metoprolol*. -newer beta blockers like nebivolol (bystolic) have fewer SEs

_________ is a major source of morbidity in older adults

Depression Depression is associated with: 1. Increased disability 2. Delayed recovery from illness and surgery 3. Excessive use of health services 4. Cognitive impairment -*mental health problems can cause cognitive impairment without any changes in the brain being present* -important to *rule out depression before misdiagnosing a patient with dementia* 5. Decreased quality of life 6. Increased suicide and non-suicide related death

Assessment of depression

Depression screening scale (GDS), H&P, functional and cognitive assessment, medication review, laboratory analysis, comorbid conditions that may be causing a person to have depressive side effects

______________ is reportable by law

Elder abuse -affects all socioeconomic, racial, and ethnic groups -Can be intentional, accidental, episodic, or recurrent

Statistically, minorities assume majority

Emerging majority

Fall prevention interventions

Fall risk reduction programs: 1. Fall bundles -Arm bands, signs, education, risk assessment, footwear, assisted toileting 2. Environmental modifications 3. Assistive devices 4. Safe client handling 5. Wheelchairs 6. Alarms/motion sensors

________ is movement of gastric contents, especially gastric acid, into the esophagus

GERD -occurs bc lower esophageal sphincter (LES) relaxes too much -common chronic disease in older adults 1. Older adult symptoms have an *atypical presentation, not necessarily heartburn*: -Persistent cough -Asthma exacerbations -Laryngitis -Intermittent chest pain: may describe heartburn as chest pain 2. Goal of therapy is *to prevent exacerbation of symptoms* -Lifestyle and diet changes (HOB up, lose weight, decrease intake of acidic foods like tomatoes, pizza, Italian or Mexican food; anything high fat or greasy) 3. Medication management: PPI's -*PPI's can cause/exacerbate OA & decrease bone density* 4. *Most serious complication = Aspiration Pneumonia*

What is the priority intervention for heat stroke?

GET THEM OUT OF THE HEAT - want to treat the underlying cause

Falls are considered what type of syndrome?

Geriatric syndrome -*Falls are a SYMPTOM of a problem* -1/3 of adults 65 and older will fall each year; 10% will sustain some type of serious injury (hip fracture, traumatic brain injury) & can lead to death *Fallophobia is the fear of falling causing limitations in function* -provide general education about preventing falls & proper body mechanics for walking to those who have this fear

__________ is the leading cause of blindness

Glaucoma -*Caused by an increase in intraocular pressure* 2 types: open & closed angle -Angle controls outflow -*Open angle most common and non-acute* -Closed-angle glaucoma is considered a *medical emergency; person must be evaluated within a day or they can go blind*

_____________ & _____________ are individuals, agencies, or corporations that have been appointed to take care, custody, and control of incapacitated person & ensure that his or her needs are met & handled responsibly

Guardians & conservators

Parkinson's Disease patho

Has genetic, viral, and toxic causes -Results in degeneration and death of neurons of substantia nigra (in midbrain - reward, addiction, & movement; sleep-wake cycles & firing of action potentials) 1. Neurons in cerebral cortex atrophy --> 2. Dopaminergic pathway degenerates --> 3. Dopamine receptors in basal ganglia decrease --> 4. Dopamine production decreases --> 5. Acetylcholine predominates --> 6. Dopamine doesn't inhibit acetylcholine --> 7. Symptoms manifest *Effects of PD are essentially result of excess acetylcholine*

OA deformities

Heberden's & bouchard's nodes are swelling of the joints in the hand caused by overgrowth of bone -*Bouchard's nodes are BELOW* heberden's nodes

Painful, vesicular rash, over a dermatome. Teach pt to get vaccine starting at age 60.

Herpes zoster (shingles)

Costs of U.S. LTC services and support programs

Homemaker services: $19/hr Home health aide: $20/hr Adult day health: $65/day Assisted living facility: $3500/month; $42000/year Nursing home care: $212/day; $90000/year Costs of LTC services and support programs at home: $1800/month -overly reliant on institutional care in the U.S. -*primarily financed by individuals or Medicaid* -Most don't plan for their LTC needs and not knowledgeable about existing resources -Majority of LTC services are provided by unpaid caregivers (aka family) -*medicare would not cover LTC unless there was some skill needed* -out-of-pocket spending accounts for about 22% of national spending for LTC

If you entered a room with two residents lying in bed together, what would you do?

If they are 2 consenting people, they have the right and you need to turn around and shut the door. If there is someone taking advantage of another person with an impairment, then another intervention will need to be done.

Safety & security

Increasing vulnerability to environmental risks and mistreatment by others as older adults become less physically or cognitively able to cope or recognize real or potential hazards -*at a higher risk for being physically & emotionally assaulted* A safe environment allows an older person to live without fear of attack, accident, or imposed interference Sensory deficits can impair the individual's awareness of dangerous conditions or imminent threats -*impaired hearing, vision, or smell increases persons risk for injury*

Intimacy vs. sexuality

Intimacy encompasses more than just sexuality: 1. Commitment 2. Affective intimacy 3. Cognitive intimacy 4. Physical intimacy 5. Love and affection ex: touch, holding, cuddling, being present Sexuality is a specific type of intimate activity: 1. Sexual acts 2. Sexual desire 3. Activity 4. Attitudes 5. Body image 6. Gender-role activity 7. Acceptance and Companionship

Red yeast rice is used to lower what?

LDL 1. Evidence leans toward supporting efficacy 2. SEs: Muscle pain, liver damage, heartburn, bloating, flatulence, dizziness 3. Contraindications: -*Liver dysfunction or elevated LFTs* -*Use with other hepatotoxic meds*

Is learning later in life still possible?

Learning is still possible because *basic intelligence remains unchanged* with increasing years

Loss of driving privileges

May have loss of driving privileges due to physical limitations or dementia -Not always individual's choice A life-changing event contributes to: 1. Social isolation 2. Increased depressive and anxiety symptoms 3. Decreased QOL 4. *Increased risk of nursing home placement* -Associated with loss of autonomy, pleasure, competence, and self-worth -Must include plan for alternate transportation with family, caregivers, or community resources

___________ is an insurance plan for persons who are *age 65, blind or totally disabled, including persons with ESRD*

Medicare -includes part A, B, C, & D

A strong holistic health movement expands the definition of health as what?

Multifactorial, realizing the potential of the individual and *how they function within the context of their environment*

Over half of elder abuse is:

Neglect -self or caregiver

Exercise guidelines

Older adults need at least: 1. 2 hours and 30 min (150 min) of moderate intensity aerobic activity (brisk walking, swimming, bicycling) AND 2. muscle strengthening activities on 2 or more days that work all major muscle groups (legs, hips, abdomen, chest, shoulders, and arms)

________ is an overuse disorder that occurs in the joints and causes inflammation

Osteoarthritis (OA) 1. Normal soft and resilient *cartilaginous lining in joint becomes thin and damaged* 2. Joint space narrows and *bones of joint rub together, causing joint destruction* 3. Diagnosis is made clinically 4. Most common symptoms are *stiffness with activity and pain with activity relieved by rest*

_________ is a neurodegenerative disease that is often diagnosed later in life & often affects older men more than women.

Parkinson's disease (PD) 1. Almost exclusively a disorder of older adults; *age of onset is approximately 60 yo* 2. Progressive disease - over 10-20 yrs -*affects the basal ganglia (corpus striatum) where dopamine is made* & involves the dopaminergic nigrostriatal pathway 3. think DOPAMINE - *dopamine is lost or inhibited* -another disorder of dopamine is schizophrenia, which is caused by EXCESS dopamine. -Parkinson's is a disorder *caused by DEFICIENT dopamine* -Acetylcholine is also a neurotransmitter that *balances out dopamine* 4. *Considered a terminal diagnosis*

Loss response model - 3 steps

Person/family/grievers are a system -loss creates chaos & disequilibrium; system must restore equilibrium Step 1: -Make sense of the loss -Search for meaning: why did this happen to us/me? -Why wasn't it me? Step 2: -Integration and acceptance of the loss -Emotions stabilized or channeled -Others step in ready to assume roles of one lost Step 3: -System redefines itself -Reframing memories -Things may be different, but that is accepted

Drug-drug interactions increase with what?

Polypharmacy -Meds may compete to simultaneously bind & occupy the same receptor site, creating varied bioavailability of one or both drugs 1. *Antispasmodics slow GI motility* even further than present in normal aging -*may prove harmful when it leads to accumulation & potential med intoxication* 2. Altered distribution may be caused by displacement of one med from its receptor site by another med or by binding of the drug to protein 3. Altered metabolism -effects on CYP450 system 4. Changes in pH -causes med to either be reabsorbed or excreted to a greater extent than is desired -*sodium barcabonate --> increases pH --> amphetamines reabsorbed* 5. Alternations in renal tubules --> prolonging half-life of some meds 6. Meds with similar side effects & MOA's -*together they become more potent than they are separately* -simultaneous sedative effects

Hearing should be screened for by who?

Primary care providers; however, this is usually not done -Screening rate approximately 13% -20% received hearing aids -this is largely due to medicare; medicare pays for hearing screenings, but does not pay for hearing aids -*Nursing intervention: nurses can screen for hearing WITHOUT an order*

Itchy skin. Use fragrance free products. Lotion

Pruritis

__________ is the most common treatment for thyroid Grave's disease & ONLY affects the thyroid gland

Radioactive iodine (RAI) 1. Absorbed by thyroid and radiation destroys thyroid tissue -attacks thyroid gland & renders it not useful 2. Contraindicated in pregnancy and breastfeeding. No pregnancy for 3-6 months post treatment 3. No evidence that this increases risk of cancer.

Silver hour - dying PCC goals

Recognition that death is imminent 1. Ensure pt. and family understands that death will occur 2. Allow family as much access to dying as possible 3. Promote shared decision making 4. Transition from life-saving care to comfort-care

Spirituality vs. Religion

Religion = organized social institution Spirituality = broader concept that embraces one's values/belief system *Spirituality is more broad & religion is more specific* *All religious people are spiritual, but not all spiritual people are religious* A person *defines their religion/spirituality for themselves* Often, *older adults become more spiritual or religious as they age because they are closer to death & want to "get right with God"*

STOPP criteria

Screening Tool of Older Persons' potentially inappropriate Prescriptions

Touch zones

Social zone: hands, arms, shoulders, back Consent zone: mouth, wrists, feet Vulnerable zone: face, neck, front of body Intimate zone: genitalia *Anything not in the social zone REQUIRES CONSENT*

Stages of pressure ulcers

Stage 1 - red, non-blanchable skin Stage 2 - top layer of skin is gone Stage 3 - down to deeper tissues; fat, muscle Stage 4 - bone is visible *Unstageable if pressure ulcer has eschar or necrotic tissue* -once it's cleaned out & necrotic tissue is removed, then it can be staged -if eschar is present, it is at least a stage 2

Garlic is used to prevent:

Stroke & arteriosclerosis 1. Mixed results from the research -Reduced blood clots, reduce LDL -Two meta-analyses show it lowers BP 2. SEs: Flatulence, bleeding risk, nausea, heart burn, hypotension, hypoglycemia 3. Contraindications: -*Use with anticoagulants; remember many cardiac patients are anticoagulated (DO NOT USE)* 4. Should be approved by healthcare provider

When do you know treatment of hypothyroidism has been effective? What labs should be monitored?

Symptom relief is a good indicator that the medication if effective. -*If the person develops HTN, chest pain, or heart palpitations - this is significant & means medications is TOO effective. In this case, medication should be held & prescriber should be notified.* Labs that should be monitored are TSH (should come back to normal & no longer be high), T3 & T4 should also normalize. -*After person has been maintained for quite a while and they have a proper dose, monitor TSH only.*

Treatment for anxiety disorders in older adults depends on _________, __________, _________, & _________

Symptoms, specific anxiety diagnosis, comorbid medical conditions, & current medications

Repeated sequences on chromosomes essential for cellular reproduction are called what? (4)

Telomeres 1. shorten with every cycle 2. hypothesized to be *contributory to senescence (aging) of the cells* 3. enzyme telomerase counteracts this effect 4. manipulation of telomeres has potential to affect development & treatment of disease & aging itself

Why does loss of height occur with OP?

The loss of height occurs because of the loss of bone mass in the spine/vertebrae. Vertebrae become less dense and start to compact. Sometimes people will have compression fractures of the vertebrae that go undiagnosed for a long period of time and can be very dangerous because if you have an unstable vertebrae, the spine can become compressed and result in neuro disorders.

Distribution

The systemic circulation transports a med throughout the body to receptors on the cells of the target organ where a therapeutic effect is initiated -*organs of high blood flow (brain, kidneys, lungs, & liver) rapidly receive the highest concentrations* -distribution to organs of lower blood flow (skin, muscles, fat) occurs more slowly & results in lower concentrations of the med in these tissues. *Circulatory diseases common in late life, such as peripheral vascular disease, can negatively affect med distribution.*

____________ is defined as the perception of sound in one or both ears or in the head when no external sound is present.

Tinnitus -Constant or intermittent -Worsens with age -Ringing, humming, buzzing, roaring, hissing, etc. -*More common in men* Risk factors: 1. Presbycusis 2. Loud noises 3. Head and neck trauma 4. Tumors 5. Cerumen impaction 6. CV disease 7. Ototoxic meds 8. Med SEs -*ASA common*

Tinnitus treatment & nursing interventions

Treatment: 1. Hearing aids -*Amplify sounds to drown tinnitus* 2. Electrostimulation, biofeedback, cochlear implants 3. Hypnosis, acupuncture, chiropractic, medication tx Nursing interventions: 1. Identify when sounds are most irritating *(can be helpful in identifying the underlying cause)* 2. Keep log/diary (document when it's worse, what does it sound like) 3. *Reduce/eliminate: ETOH, caffeine, cigarettes, stress, and fatigue* 4. Refer to American Tinnitus Association

Echinacea is used to prevent and treat:

URIs 1. Some studies show it can halt or shorten a cold 2. Possible immune stimulant qualities 3. SEs: Fever, sore throat, N/V/D, abd pain 4. Contraindications: Allergy to daisy plant, HIV, autoimmune dz, with APAP

An 80 year old client is taking a second generation antipsychotic. Which of the following interventions should be performed to monitor for complications? Select all that apply. a. assess temp b. assess pain level c. assess gait d. assess BP e. assess respirations

a. assess temp c. assess gait d. assess BP e. assess respirations

Gerontology is the scientific study of the process of:

aging and the problems of aged persons including physical, mental, and social -*holistic*

Stress overload in late life is increased by:

changing environmental needs and reduction of biopsychosocial homeostatic resilience

Cognitive reserve (CR) is the ability to:

compensate for age-related changes -"Use it or lose it" applies to cognitive function as well as physical health -Based on concept of neuroplasticity - *capacity of the brain to change in response to stimuli* To maximize cognitive reserve, want to *engage older adults in cognitive, sensory, & motor activities* -*engage in meaningful social interaction regularly*

Geriatrics is the branch of medicine that deals with the:

diseases & treatment of older people

The group of people with the shortest life expectancy in the U.S. are:

African American males. They have an average life span of 71.8 years -- this is a major health disparity. *This group is only expected to reach their 70th birthday or very early 70's*

_________ & __________ are risk factors for both hypo & hyperthermia

Alcohol use & inadequate housing

An 80 year old client tells the nurse that their thinking is not as sharp as it used to be. After assessing a negative screen for cognitive impairment, what should the nurse tell the client? A. "I'm going to inform the healthcare provider of this unusual issue" B. "Sometimes the speed of our thought processes slows as we age" C. "you don't need to worry about this expected part of aging" D. "A medication called donepezil (Aricept) will improve this issue"

B. "Sometimes the speed of our thought processes slows as we age"

What drug is avoided in the treatment of anxiety in older adults?

Benzodiazepines - *can be very sedating* -if benzodiazepines are necessary, *ONLY short-acting benzodiazepines should be used.* -Long-acting benzodiazepines are in the system longer and therefore are more sedating.

PD - anticholinergics

Benztropine (Cogentin), trihexyphenidyl (Artane) -*cogentin works on increasing dopamine but also limiting acetylcholine* 1. *Block* the excitatory action of *acetylcholine* 2. May be used synergistically with Levodopa/Sinemet 3. *Used early in disease or when Levodopa not tolerated* 4. *Helps prevent PD symptoms of drooling, tremors, rigidity* 5. Anticholinergic SEs -*can't see, can't pee, can't spit, can't shh* (blurred vision, urinary retention, dry mouth, constipation) 6. Assess for signs & symptoms of glaucoma & photophobia (sensitivity to light) Client education: 1. *Avoid activity which promotes fluid loss* 2. Don't stop taking abruptly

Yeast infection often in skin folds. Keep skin clean and dry. Keep DM in check.

Candidiasis

A pat on the head or squeezing of the toes when entering a patient's room is considered:

Condescending touch

Shared and learned beliefs, expectations, and behaviors of a group

Culture

Touch deprivation

Desire for touch is more powerful in old age as other sensual experiences are diminished and direct sexual expression is not possible or available Cause of illness may be greatly influenced by quality of tactile support received Higher death rates are more related to quality of human relationships than to degree of cleanliness, nutrition, & physical disabilities on which we focus

Hyperthyroidism diagnosis & mainstay medication

Diagnosis: 1. TSH, T3, T4, free T4, EKG, ELISA to measure autoantibodies 2. Physical exam and history Treatment: antithyroid agents -Want to decrease the production of thyroid hormone 1. Methimazole (Tapazole) -*inhibits thyroid hormones by blocking the oxidization of iodine in the thyroid gland.* Inhibits synthesis of thyroid hormone. Does not block peripheral conversion to thyroid hormone

Dysphagia

Difficulty swallowing; very common in older adults -After the age of 50, 20% have some degree of dysphagia. -Begins early; not necessarily due to any underlying condition, can just be due to aging. Things like *loss of muscle tone can be leading to this* -Up to 60% of LTC residents have some degree of dysphagia -Cause can be behavioral, sensory, or motor. Can result from a stroke Complications: 1. Weight loss 2. Malnutrition & dehydration 3. Aspiration pneumonia -*aspiration is a serious complication of dysphagia & can cause pneumonia --> sepsis --> 4. death*.

Factors affecting intimacy & sexuality in LTC facilities

Environmental Factors: 1. Lack of privacy 2. Absence of suitable partner 3. Family and staff attitudes 4. Dementia

Calculation of creatinine clearance in elderly

Equation based on age & body weight

More older adults die from _____ than from all other natural disasters combined

Excessive heat Hyperthermia is caused from excessively hot environment - *can't have hyperthermia in response to infection*

The family member of a patient asks if vitamin C will prevent aging. In formulating an appropriate response, the nurse considers the:

Free radical theory

When an older person retires, they are often _______ & _________

Happier & healthier -have more time to care for themselves -have more time for social interaction & family involvement

Before cerumen removal, ask patient if:

He or she has ever had a problem with his or her eardrum and is currently having ear pain or drainage -using an otoscope, gently insert it in the ear canal while pulling up on the auricle; while doing so, examine the canal for trauma and the presence of excess cerumen or cerumen impaction (when the TM is not visible or only partial visible)

___________ is the absence of disease

Health

The person appointed as ________ is responsible for making medical decisions for persons when they are unable to do so for themselves.

Health Care Power of Attorney/Surrogate

Differences in the state of health and in health outcomes between groups of persons

Health disparity

Excess burden of illness, or the difference between the expected incidence and prevalence and that which actually occurs in excess, in a comparison population group

Health inequity

Most older adults describe _________ as the worst sense to lose

Hearing -*Most common communication disorder* -3rd most common chronic condition in older adults -*Men more affected* -Underdiagnosed and undertreated -QOL diminished: decreased function, miscommunication, falls, low self-esteem, cognitive decline

What should be avoided 7 days before testing of thyroid function?

Hormones, steroids, ASA, foods containing iodine

Do older adults have a high or low health literacy?

Low -Nearly all (9/10) have low health literacy

What needs must be met to some degree before one is ready for recreation & creative acts?

Maslow's lower four levels must be met to some degree: physiological, safety & security, belongingness & love, & esteem needs -when a person has reached self-actualization, they are participating in recreational activities Nurses need to assess readiness (in terms of needs met) for challenge, change, & creative expression

_______________ provides health services for *low-income children, pregnant women, those who are permanently disabled, and persons age 65 and older* who are eligible

Medicaid -Health insurance program *jointly funded by federal and state governments using tax dollars* -*eligibility determined by the state* (a person living in TN would have TennCare)

A major complication of hypothyroidism is ______

Myxedema coma Causes: 1. Untreated hypothyroidism -either person has not been diagnosed or has stopped taking their meds 2. External stressors: Surgery, trauma, infection, excessive exposure to cold temps *Manifestations are all going to be LOW:* 1. hypothermia, hypoventilation, hypotensive, hyponatremia, hypoglycemia 2. Resp. distress, coma, bradycardia as a result of decreased CO Treatment: 1. Treat underlying cause 2. Stabilization of vitals 3. Thyroid hormone replacement -can be given PO or IV in hospital

_________________ are 5.7 times more likely to have DM than whites

Native Americans

The most common & most feared symptom in older adults is what?

Pain at end of life -comprehensive & multifactorial assessment by interdisciplinary team is key to appropriate management, along with interventions

Medicare part ______ is an elective prescription drug plan (PDP) with associated out-of-pocket premiums and co-payments.

Part D

Hypothyroidism patho

Patho 1. Thyroid fails to produce adequate TH --> 2. low T3 & T4 --> 3. hypothalamus & pituitary create & release more TSH --> 4. possible period of compensation (subclinical hypothyroidism) --> 5. TH remains low even though TSH is elevated --> 6. Signs & symptoms manifest --> 7. *thyroid gland may become hypertrophied (increase in size)*

Primary vs. idiopathic parkinsonism

Primary parkinsonism: known cause or r/t secondary effect of another disorder Idiopathic parkinsonism: cause unknown or unidentified

Healthy People 2020 (4)

Provides science-based, 10-year national objectives for improving the health of all Americans 1. Eliminate preventable disease, disability, injury, and premature death 2. Achieve health equity, eliminate disparities, and improve the health of all groups 3. Create social and physical environments that promote good health for all 4. Promote healthy development and healthy behaviors across every stage of life

In regards to use of restraints on older adults, what is the goal for care?

Restraint-free care -should not be used to manage behavior symptoms -treat the underlying problem

First-line drug for anxiety and depression in older adults

SSRIs -well-tolerated & work the best -*major issue with SSRIs = sexual side effects (decreased libido)* -if sexual side effects are a problem for the person, *they will be switched to SNRIs*

Antidepressants - SSRIs & SNRIs

SSRIs 1. First line 2. Work well in older pts 3. Small doses effective 4. Often have sexual side effects - switch to SNRIs SNRIs 1. Second line 2. Less sexual side effects 3. Bupropion (welbutrin) -reduces nicotine dependency as well 4. Trazodone -also used as a sleep aid

Nursing research related to gero (6)

Studies on: 1. dementia *(top priority in nursing research of older adults)* 2. reducing falls 3. use of restraints 4. pain management 5. delirium 6. humane end-of-life care

The wellness model suggests what?

That every person has an optimum level of functioning for each position on the wellness continuum to achieve a good and satisfactory existence

Effects of elderspeak

The implicit message of incompetence then begins a negative feedback loop for older persons, who *react with decreased self-esteem, depression, withdrawal, and the assumption of dependent behaviors.*

If you saw a male resident with dementia masturbating in the common area, what would you do?

Throw a sheet over them, and take them to their room. You wouldn't scold or make a big deal about it, you would just get him away from everyone else.

____________ is 10 times stronger than verbal or emotional contact

Touch -*Most neglected of the senses* Response to touch: 1. Procedural vs. non-procedural touch -must have permission/informed consent for procedural touch 2. Boundaries of touch is often cultural 3. Don't assume one wants to be touched 4. A handshake (if appropriate) gives a lot of info -Firm or soft, fast or hold on, warm or cold, sweaty or dry

_________________ is the high-level emotional response to religious and spiritual life

Transcendence -detachment from traditional life; see life in a different light Gerotranscendence is focused on the older adult transcending

Majority of documented elder abuse cases are:

White elders (84%) -not much of a disparity here, minority groups are just less likely to report elder abuse Most abuse: -*occurs in home* -*by spouses or adult children*

Dry, cracked, itchy skin. Increase fluid intake. Use gentle, moisturizing soaps

Xerosis (condition which can lead to itchy skin)

The nurse determines that teaching to prevent constipation was effective in a client who states which of the following?

"I will walk 20-30 min daily"

The nurse knows that the patient has a good understanding of her height loss when she states:

"I've gotten shorter because my back curves more and the spaces in my spine are smaller"

The nurse is teaching a 72 year old female client about normal changes that put her at higher risk for urinary incontinence. Which statement below indicates the need for further teaching?

"My kidneys make more urine now"

In order to receive even the minimum monthly income from social security, a person must have worked enough to have earned an adequate number of ________

"credits" -In 2014, one credit was equal to an income of $1200 in any one year with a maximum of four credits possible. -In order to receive social security retirement income, those born after 1929 have to *obtain a minimum of 40 credits in a lifetime.* Only income from which social security taxes are withheld can be used toward a credit -*most beneficial to white men*, who are more likely to have worked the most consistently & at higher salaries -*least beneficial for those who were low wage-earners, who never worked out of the home (housewives), or who took time out of the job market* for caregiving & childrearing activities.

Home safety evaluation - problems & interventions for bathroom

*Bathroom is the MOST dangerous place in house for older adult* 1. getting on & off toilet: raised seat, side bars, grab bars 2. getting in & out of tub: bath bench, hand-held shower nozzle, rubber mat 3. hot water burns: check water temps before bath, set hot water thermostat to *120 F or less* 4. doorway too narrow: remove door; leave wheelchair at door & use walker

Hyperthyroidism manifestations

*Bc metabolic rate is increased, EVERYTHING IS INCREASED* 1. Goiter 2. exophthalmos: bulging eyes - *eyeballs protrude bc of increased fat production behind the eyes* 3. insomnia 4. tremors 5. from oligomenorrhea (infrequent periods) to amenorrhea (absence of menstruation) 6. HTN 7. tachycardia 8. *A-Fib* -*major complication which can increase person's risk for stroke* 9. fine and thin hair 10. moist and flushed skin 11. weight loss 12. *fluid volume deficit from heat intolerance & increased sweating*

OA goals of therapy are to:

*Control pain and minimize disability* Pharm therapy: 1. *acetiminophen (tylenol) is best* -bc older adults are usually the ones to have OA, *try to avoid NSAIDs bc they are nephrotoxic & cause CV complications* -4 gram max per day 2. NSAIDs: COX2 (selective NSAID; avoiding ibuprofen) 3. Joint injections - Intra-articular -Steroids: Inflammation -Hyaluronic Acid: Lubrication Non-pharmacological therapy: 1. Exercise - "Motion is the Lotion" -Strength and flexibility: support the joints -Water exercise is good bc person is not putting as much weight on their joints but at same time is getting the movement 2. Physical therapy 3. Hot/Cold therapy: depends on patient preference 4. Adaptive devices -Cane: Relieves hip pressure by 60% -Shoe lift for back pain -Knee brace for stability Surgical intervention: knee/hip 1. Arthroscopy 2. Total Joint Replacement 3. Lower back/lumbar spine surgery (spinal fusion) -*big complication of OA in lumbar spine is spinal stenosis* -*if you have spinal stenosis, you have an increased risk for neuro complications*

Home safety evaluation - problems & interventions for kitchen

*Kitchen is also extremely dangerous for older adults* 1. open flames & burners: *avoid using.* substitute microwave, electric toaster oven 2. access items: place commonly used items in easy to reach areas, adjustable height counters/cupboards 3. difficulty seeing: adequate lighting, utensils with brightly colored handles

The LEARN model for communication

*L* - *listen* carefully to what the elder is saying. Verbal and nonverbal. Meaning behind the stories. Listen to perception of the situation, the desired goals and ideas for treatment. Explain your perception of the situation and the problems. *E* - *explain* your perception of the situation & the problems *A* - *acknowledge* and discuss both the similarities & the differences between the perceptions & goals *R* - *recommend* a plan of action that takes both perspectives into account *N* - *negotiate* a plan that is mutually acceptable

Laxatives (4)

*Listed in order of how we should try to administer them* 1. Bulk-forming (fiber)- psyllium (Metamucil) -*First line and contraindicated in very frail elders or those with dysphagia*; need to drink metamucil really fast or it gets thick like a gelatin, therefore those with trouble swallowing should not take. 2. Emollients - docusate sodium (stool softener) -*pulls moisture into stool* to help prevent constipation 3. Osmotic- milk of mag, lactulose -more powerful & *causes a greater shift of water into the stool* -lactulose is used in pts with liver failure to decrease levels of ammonia, but can be used as a laxative in those who don't have liver problems -*Often causes diarrhea so need to assess electrolyte levels* 4. Stimulant - bisacodyl -Stimulates peristalsis -*would like to avoid in older people; have an increased risk of causing a bowel perf with the increase in peristalsis & squeezing* -Often causes cramping -May cause dehydration and electrolyte disturbances

Hypothyroidism manifestations

*OPPOSITE OF HYPER* 1. Slowing in physical and mental activity -*Often noticed first but ignored* 2. Cold intolerance 3. puffiness 4. decreased sweating 5. coarse hair and skin 6. fatigue 7. low HR, BP, & cardiac output 8. weight gain 9. constipation 10. infertility 11. elevated LDL, low HDL (arteriosclerosis) 12. possible goiter -*can have goiter with both hypo & hyper* for different reasons; *with hyper, goiter or enlarged gland can be the cause of hyperthyroidism.* Have too much thyroid tissue causing too much TH production -*with hypo, a goiter is developed as a compensatory action.* Body has detected there's not enough TH, so gland will begin to enlarge to produce more

PAINED - pain assessment

*P*ain is real (Believe the patient!) *A*sk about pain regularly *I*solation (psychological and social problems) *N*otice nonverbal pain signs *E*valuate pain characteristics *D*oes pain impair function?

Dentures (7)

*Priority in older adults if they have them - extremely expensive & insurance does not pay for this* 1. Need to be brushed just like natural teeth daily 2. Rinse after meals 3. Wear constantly during day 4. Remove while sleeping -*Must be kept in water to prevent warping* 5. Dentures are personal and expensive -Often lost, broken, or mixed up in healthcare settings. *Putting them in a plastic bag is inappropriate; storage is very important.* 6. Ill fitting dentures may lead to malnutrition -*need to assess that dentures are fitting properly. If not worn consistently, gums can change shape* -can cause pressure ulcers in the gums & cause pain & sores 7. Encourage to eat fruits and veggies -Denture wearers often consume more soft foods

Collective actualization - politics & power

-Older people are a powerful political group -Politician wishing to remain in office must gently manipulate programs such as Social Security and Medicare -Older voters are often *more concerned about candidate's character and experience than about party affiliation*

Typical resident of LTC facility

1. *Women > 80 yrs* 2. *Widowed* 3. *Dependent in ADLs & IADLs* 4. Chances for older person to live in LTC is 4-5% - will grow over time 5. If 85 yo - 1 in 2 chance of spending some time in NH 6. 23% of Americans die in NH - expected to grow to 40% by 2040

Fire safety - 3 risk factors

1. Economic or climatic conditions may promote use of *ill-kept heating devices* 2. Attempts to *cook over open flame while wearing loose-fitting clothing* 3. *Inability to manage spattering grease from frying pan can often start fire* from which elder cannot escape

5 types of aphasia

1. Fluent Aphasia -Inability to *perceive/understand speech* -Reading and writing impaired -*RECEPTIVE aphasia* 2. Nonfluent Aphasia -*Impaired speaking* -Speech is effortful -*EXPRESSIVE aphasia* 3. Verbal *Apraxia* -*Inability to move mouth, tongue, diaphragm* as the brain directs -Frequently occurs with aphasia 4. Anomic Aphasia -*Severe word finding difficulties* 5. Global Aphasia -*Can't understand or express* -*Says meaningless things*

Most common causes of non-cancer pain in older adults are: (2)

1. Musculoskeletal -arthritis, degenerative spinal conditions 2. Neuropathic -diabetes, PVD, herpes zoster, stroke

Physical factors influencing the grieving process

1. Number of concurrent medical conditions 2. Use of sedatives (delays but doesn't lessen grief) 3. Nutritional state: if inadequate, reduces the ability to cope or meet demands of daily living; inadequate rest can lead more quickly to mental & physical exhaustion 4. Exercise: if inadequate, limits emotional outlet; may increase aggressive feelings, tension, & anxiety

Endocrine 5 changes

1. Reduced insulin secretion & increased insulin resistance (type 2 diabetes) 2. Mineral metabolism affected by decreased vitamin D synthesis, altered parathyroid hormone activity, estrogen decline in post-menopausal women with increased bone osteoclast activity 3. Fluid/electrolyte balance affected by decreased renin-angiotensin-aldosterone activity, increased atrial natriuretic hormone 4. Body composition affected by decreased growth hormone, altered glucocorticoid & testosterone (males) activity 5. Decreased adrenal functional reserve & hormonal response

3 effects of stress in late life

1. Reduces coping ability 2. Impairs neuroendocrine response that blunts immune function 3. Can lead to cancer, Alzheimer's disease, frailty, and functional decline

Nurse's role in end of life decisions/advanced directives

1. Resource person 2. Inquire about presence of advance directives 3. Implementing advance directives 4. Keeping documents available in medical record

Geriatric orphans

1. Those without family support during the dying process 2. "No one dies alone" campaign (1986) - someone sits in the room with the patient while they are dying. 3. Seek out an opportunity to be with someone when they die - If it's not your patient, try to stay close to the nurses caring for them. If it is your patient, try to stay close by and do as much as possible.

Thyroid hormones

1. Thyrocalcitonin -*Lowers plasma calcium* by inhibiting the mobilization of calcium from bone 2. Tetraiodothyronine (T4) -More prevalent in blood, but T3 is stronger -*Longer half life than T3* -T4 converted to T3 in peripheral tissues 3. Triiodothyronine (T3) -*5 times stronger than T4 (more potent)* and has a more rapid metabolic action though it's only present in blood in very small amounts.

Common bruising patterns of abuse

1. Wrap around bruises -Accidental bruises don't form a wrapped appearance -A bruise that wraps around the *wrist, arms, neck, or ankle* may indicate force -*Look for thumb pad on one side and finger pads on the other* 2. Linear bruising -Accidental bruising doesn't follow linear pattern -Striking with an object can cause linear bruising -*May be seen on back, buttocks, thighs, or arms*

Cultural variation & abuse - Vietnamese

1. family problems to be kept at home; can't be disclosed to outsiders 2. neglect brings shame to family 3. *psychological silent treatment most serious & reported*

Cultural variations & abuse - Korean

1. financial exploitation defined in U.S NOT considered a form of abuse 2. *high tolerance for neglect* 3. placing in nursing home *shameful and form of abuse*

2 types of intelligence

1. fluid intelligence: biologically determined skills *independent of learning or experience* -can equate this to *common sense*, abstract thinking, *REASONING,* ability to draw conclusions 2. crystallized intelligence: knowledge and skills *acquired during life* -Verbal meaning, word association, social judgment, number skills

Emotional or spiritual signs & symptoms of approaching death

1. withdrawal: prepares pt for release, detachment, & letting go -continue communicating in a normal manner using a normal voice tone; identify self by name; give permission to die 2. vision-like experiences of dead friends or family; religious vision: preparation for transition -accept the reality of the experience for the person; reassure him or her that the feeling is normal 3. restlessness: tension, fear, unfinished business -listen to pt express his or her fears, sadness, & anger; facilitate completion of business if possible 4. unusual communication: signals readiness to let go -say what needs to be said to the dying pt; kiss, hug, cry with him or her as appropriate

Nearly ____% of older adults over the age of 55 experience mental health disorders that are:

20%; *not a normal part of aging* -increased stress, anxiety, & depression are common in older adults, but NOT normal Mental health disorders in older adults are underreported & not well researched -mental health can be affected by cognitive & affective functioning earlier in life

Nearly ___% of hypothermia deaths occur in older adults

50% 1. *Defined as core temperature < 35 º C (95 º F)* 2. Mild, moderate, or severe depending on core temperature 3. Can occur with *exposure to extreme cold environmental conditions* or *exposure in room temperature without protection* 4. *First Sign = mental status change*; may be confused & disoriented 5. *GOAL: Temp >97º F* -if person's normal temp is in 96's that's okay as long as it's within their baseline. -should begin intervening before they get to 95

More than ___% of older adults over the age of 50 don't get enough exercise, while ____% over 75 don't get enough.

60% over 50; 90% over 75

______% of people with dementia live at home

70% -Most of the people who care for those with AD (2 out of 3) are a *female relative*

The nurse is caring for an older client who experienced a hip replacement surgery 10 hours ago. Which intervention will help minimize this client's risk of developing delirium? A. offer fluids frequently B. administer sleep aids C. encourage to remain still to reduce pain D. limit visitors to family only

A. offer fluids frequently

Acute vs. persistent pain

Acute pain 1. temporary 2. postoperative, procedural, & traumatic pain 3. often well controlled by analgesic Persistent pain 1. no time frame 2. persistent at varying levels of intensity 3. more difficult to treat

Risk factors for changes in fluid balance

Adequate fluid consumption & maintenance of fluid balance is essential to health 1. Physiological changes in body water content -older adults *seem to dehydrate more easily than younger adults bc they have a lower baseline level of body fluid & water in their body. They also have less muscle content which holds fluid better than fat content.* 2. Impaired thirst sensation 3. Medications 4. Functional impairments 5. Chronic illness 6. Emotional illness 7. High environmental temperatures

End of life decisions

Advance Directives Morally (and often legally) binding documents: 1. Expression of wishes when unable to make decisions 2. Living Wills 3. Durable power of attorney for healthcare: an appointed person who makes medical decisions for someone when they can't make decisions for themselves 4. DNR/DNI status: a DNR is not a legally binding document, it's a HCP order & can sometimes be overturned by family; goes against the dying person's wishes

__________ is considered normal memory loss

Age-associated memory impairment (AAMI) -general slowness in processing, storing & recalling new information AND difficulty in remembering names and words -*Offset with cognitive stimulation and memory training*

3 other medications used to treat hyperthyroidism

Another antithyroid agent: 1. propylthiouracil (PTU) -*Blocks oxidation of iodine* in thyroid gland, *inhibiting thyroid hormone production.* -*Inhibits conversion of T4 to T3* (which is more potent, active) -SEs same as Tapazole *plus Lupus like symptoms (rash on face, fatigue)* -Assess thyroid function tests, for signs of hypothyroidism, urticaria -*Don't give with potassium iodide* 2. Iodides: potassium iodide (SSKI) -Inhibits thyroid hormone secretion by *decreasing vascularity of the thyroid gland,* causing it to be less well-perfused & not work as well as it's supposed to -*Generally given during thyroid storm and for short period of time*. -SEs: N/V/D, abd pain, parathesias, weakness, confusion, signs of hypothyroidism, acne -*Give solution in full glass of water or juice* *(NOT GIVEN WITH MILK)* -Report severe GI disturbances, avoid foods high in iodine, increase fluid intake 3. Beta blockers: propanolol (inderal) -*Competes with epinephrine and norepinephrine* for beta receptor sites. *Slows rhythm conduction and contractility.* -*Symptomatic treatment of hyperthyroidism and possibly A-fib.* -Assess apical pulse and BP before admin -*Teach pt to measure own pulse and BP.* Report persistent dizziness, SOB, or syncope.

Health promotion for mental health

Assess: 1. Risk factors of life transition, loss, and loss of social support 2. History of ability to cope with stress and life events 3. Assessment of cognitive function and/or impairment 4. Assessment of substance abuse and suicide risk Interventions: 1. Enhancing characteristics of hardiness, resilience, and resourcefulness 2. Enhancing functional status and independence 3. Promoting sense of control 4. Fostering social supports and relationships 5. Education regarding available resources *improve coping --> prevent stress --> prevent development of mental health problems*

Functional assessment - ADLs

Assesses person's ability to perform tasks of *self-care* -Needed to *maintain one's health* -*Tool: Katz*

The nurse identifies which client to be at the greatest risk for experiencing health disparities and inequities? A. A 72 year old Caucasian male who has Medicare B. A 63 year old Hispanic female who lives in low-income housing C. A 68 year old African American female who lives in an assisted living facility D. An 81 year old Caucasian female who participates in "Meals on Wheels"

B. A 63 year old Hispanic female who lives in low-income housing

TedEd q - About how many of Peter Saul's cells died while you watched this talk (assuming you watched it straight through without stopping)? A. One million cells B. One hundred million cells C. Two thousand cells D. It's a video of a talk, so technically none of the cells died while I watched it

B. One hundred million cells

Who was most affected by the recession in 2009?

Baby boomers -many baby boomers plan to work past 65 or never retire

PD - dopamine agonists

Bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip) 1. Dopamine agonists *MIMIC effects of dopamine* in the brain; can't convert to actual dopamine like levodopa, but can act on receptors & mimic it 2. Often used synergistically with levodopa 3. Similar side effects to levodopa Client education: 1. Same as levodopa 2. *Don't stop taking abruptly* 3. *May cause compulsive behavior*

Bony deformities on feet. May have custom shoes made, surgery, or steroid injection to treat.

Bunions

Non-benzodiazepine anxiolytic agents

Buspar (Buspirone) -works well for anxiety & is taken daily. -*takes a while to reach full effectiveness*, but it is not sedating

An older client takes lorazepam as needed for anxiety and drinks 3-4 glasses of wine per day. Which of the following complications should the nurse place as highest priority? A. tachycardia B. reduced appetite C. oversedation D. liver damage

C. oversedation

Classic triad (motor dysfunction) of PD

Classic triad (motor dysfunction) 1. Cogwheel rigidity -Arms, legs, neck affected -Small *jerking movements when affected muscles stretched* -*Muscle rigidity* 2. Bradykinesia/dyskinesia (slow, difficult walking) -*All skeletal muscles affected* -Difficulty starting, continuing, and or coordinating movements -Shuffling -May become frozen (Akinesia): *absence or poverty of movement* 3. Resting/Non-intention tremors -*head, neck, face, lips, tongue, jaw, hands, & feet most affected* -Fine, rhythmic, purposeless tremors -*Disappear with sleep and purposeful movements* -Pill rolling, small handwriting, low monotone voice Complications of this triad: 1. falls -often caused by altered gait (slow start, short steps, "shuffle") & stooped posture. -*teach person to think about their movements, think about where their feet are moving, & pick up their toes* 2. fractures 3. impaired communication 4. social isolation

Type of hearing loss in which vibrations can't get to tympanic membrane or TM is impaired is called:

Conductive hearing loss Causes: 1. Infection, otosclerosis, perforated TM, fluid in middle ear 2. Cerumen impaction common cause -Cerumen thicker with age -*African Americans, those with hearing aids, and men with increased ear hair are at higher risk* *Treatment = eliminate underlying cause*

Creatinine vs Cockcroft Gault equation

Creatinine -In general, more accurate measure of renal function -Used to diagnose and monitor renal insufficiency -*normal: 0.6-1.2* Cockcroft Gault equation -estimates renal function -creatinine clearnace -used instead of 24 hr urine -used to dose possible toxic drugs

What the nurse brings to the caring situation and what the nurse learns about older adults, their families, their communities, their behaviors, and their expectations

Cultural knowledge

The nurse performed a geriatric depression scale assessment on a 76 year old client and suspects a positive screen for depression and suicidality. What is the priority nursing intervention? A. Notify the healthcare provider immediately B. Document the assessment findings C. Repeat the screening on a separate day D. Ask client about current self-harming thoughts

D. Ask client about current self-harming thoughts

TedEd q - What is the "big idea" concerning end of life care that Peter Saul discusses? A. The ICU should develop better methods to help the increasingly frail live longer B. The medical industry should make faster advances in lifesaving technologies C. Euthanasia should become a culturally-accepted and government-funded program D. The process of dying should be reclaimed from the current medicalized model

D. The process of dying should be reclaimed from the current medicalized model

__________ may affect up to 42% of hospitalized adults and 87% of older adults in intensive care units

Delirium -Associated with *increased length of stay, increased use of healthcare services post discharge, and morbidity, mortality, and institutionalization,* independent of age and comorbid illnesses -causes significant distress for patient and family -*considered a medical emergency* -Cognitive changes in older people often labeled as confusion by nurses and physicians; frequently accepted as part of normal aging - this is a stereotype. *Important to know what the patients baseline mental status was prior to admission* -*delay in treatment contributes to negative outcomes with delirium*

Oral care

Dental health is often neglected in older adults If client has teeth: 1. Need teeth brushing and flossing daily 2. *Ultrasonic toothbrush best* -cleans better, takes less time, massages the gums & encourages blood flow 3. Foam swabs help to moisturize but don't replace brushing 4. *Never use lemon glycerin swabs in older adults* 5. Rinses and mouthwashes ok If no teeth: -Same care, just don't need flossing

Adequate ______ is an important factor in delaying onset & managing chronic illness associated with aging

Diet -Adequate nutrition is a *key factor in maintaining the health of older adults* -Proper nutrition includes all the essential nutrients: carbs, fat, protein, vitamins, minerals, water. -MyPlate: half of plate is fruits & veggies; water should be mainstay of diet in older adults

An example of ageism is the use of:

Elderspeak -Assume all older people can't hear, understand, or comprehend -Very common between nurses and clients -Used because of tradition, modeling by others, unawareness, intent to control, & insensitivity

Role of assistive technology

Gerotechnology term used to describe *assistive technologies to help older people have a better QOL & stay in their homes longer* -"Smart Homes" -Telemedicine & "smart medical homes" - monitor gait, behavior, & sleep -Environmental control systems -"Smart carpet" - detects gait abnormalities -Remote-control monitoring systems - auto lights, watering plants -Motion and pressure sensors - detects movement -Robotic technology -Facial recognition and memory aids *things to possibly educate people about if they're having issues*

Suicide interventions

If suicide risk is suspected, *ask direct questions* 1. Have you ever thought about killing yourself? 2. How often have you had these thoughts? 3. Do you have a plan to carry it out/How would you do it? -*if a person does reference ending their life, you MUST ask if they have a plan.* -anyone who has a plan *must be hospitalized; this is a medical emergency* -a person who has thoughts of suicide but does NOT have an active plan (moderate & low risk patients) may be treated as outpatients as long as they have adequate social support & no access to lethal means

Glaucoma patho

Imbalance between inflow and outflow of aqueous humor (may be too much aqueous humor being produced or aqueous humor may not be able to drain adequately) --> increase in aqueous humor --> increased IOP --> impaired vision --> possible blindness if not treated

Assessment of mood - 3 tools

Important to assess mood -with older adults, *new onset depression is NOT uncommon* Untreated depression can lead to more *functional impairments, prolonged hospitalizations, decreased QOL, & increased morbidity* Tools to assess mood: 1. Geriatric Depression Scale 2. Centers for Epidemiologic Studies Depression Scale 3. Cornell Scale for Depression in Dementia

OP prevalence & complications

In 2010 - 16.2% of adults over 65 yrs had lumbar spine or femur OP *(femur OP frequently results in hip fracture)* -*Women > men* -80+ > 65-79 yrs; *older you are, the higher the chance of having OP* -Mexican-American > non-Hispanic white > non-Hispanic black Complications: 1. *Most serious health consequence of OP is morbidity and mortality resulting from falls* 2. *20-24% of adults with hip fractures die within one year* 3. *One in five will require long term care* (think about cost & social issues within family) 4. *Only 15% will be able to walk unassisted six months post fracture* 5. Women with osteoporotic fractures have increased incidence of other major complications 6. *Vertebral fractures often not recognized* - Silent 7. Several new treatment options available: kyphoplasty/ vertebroplasty -generally meds are given

______ is disturbed sleep in the presence of adequate opportunities and circumstances

Insomnia -diagnosis of insomnia requires that the person has *difficulty falling asleep for at least 1 month* Classified as primary & comorbid 1. primary insomnia: implies that no other cause of sleep disturbance has been identified 2. comorbid insomnia: more common & is associated with psychiatric & medical disorders & medications Medications & substance instigators: 1. *Drugs & alcohol account for 10-15% of insomnia* -alcohol causes bad quality sleep; stay in earlier sleep stage 2. Meds: SSRIs, antihypertensives, anticholinergics, diuretics, stimulants, etc -remember to first do an assessment of meds & find alternatives if necessary -times of day that meds are given can also contribute to sleep problems *Eliminate the underlying cause of the insomnia*

Life expectancy of older adults in the U.S.

Life expectancy for all races & both sexes is 78.9 years old -white: 78.7 -black: 75.1 Average life expectancy for males of all races is 76.5 -white: 76.2 -black: 71.8 Average life expectancy for females of all races is 81.3 -white: 81.0 -black: 78.0

The "Beers List" (do not use list)

List is divided into 3 broad medication groups: 1. those to avoid in older adults regardless of disease or condition -*older adults should NOT take benadryl; risk is greater than the benefit of it* -if pt is taking a med that is contraindicated, ask how long they have been taking it -if prescriber gives something that is on the list or has a high risk of drug interactions, falls, sedation, etc -- talk to the HCP 2. those considered potentially inappropriate when used with certain conditions 3. those that should be used with caution

Age-related macular degeneration manifestations & diagnosis

Manifestations: 1. Blurred and dark vision 2. Scotomas -Blind spots 3. Metamorphopsia -Vision distortion (visual field is wavy & dark) Diagnosis: 1. Drusen seen on ophthalmoscopy 2. Fundus photography 3. IV angiography and fluorescein

Medicare part ________ is a hospital insurance plan covering acute care, short-term rehabilitation in a skilled nursing facility or at home and most of the costs associated with hospice care

Part A -Those who have not paid an adequate amount into the U.S social security system may be eligible to purchase Part A coverage for a monthly fee

Study of medications acting on receptor sites is called what?

Pharmacodynamics -agonize (initiate) or antagonize (inhibit) -Molecule (medication) fits into the receptor protein. When binding occurs, a structural change in the receptor protein is initiated, which in turn leads a biochemical cascade and resultant therapeutic effect. -The older a person becomes, the more likely he or she will have altered & unreliable pharmacodynamics.

Movement and action of medications in the body is called what?

Pharmacokinetics -Concentration of the medication at different times depends on how the med is taken into the body (absorption), where the med is dispersed (distribution), how the med is broken down (metabolism), & how the body gets rid of the med (excretion)

Medication for ED & nursing consideration

Phosphodiesterase inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) Nursing consideration: *should NOT be taken concurrently with nitroglycerin.* -ED meds work by vasodilation, which is also how nitroglycerin works -*can cause profound vasodilation causing acute hypotension and syncope* -does not mean that a person taking nitro can't use these, they just shouldn't be taken within same time frame/same day -ED meds were originally used to reduce pulmonary HTN

Pressure ulcers

Pressure ulcers, like pain, are a *BIG indicator of nursing care.* When a person's pain is not controlled or person develops a pressure ulcer, that always reflects directly back on the nurse. Highest incidence reported in: 1. hospitalized or institutionalized older adults -sometimes very difficult to prevent in older adults bc they're cachexic & skin is very fragile, but still need to be doing interventions & documenting them 2. vulnerable adults undergoing orthopedic surgeries -in surgery for long periods of time in the same position, increasing the risk for pressure ulcers. -also, when a person goes to the OR, they're moved around a lot, increasing risk for snags, tears, & friction -Pressure ulcers can significantly impair recovery & rehab & impact QOL -*increased risk of mortality, mainly due to infection* -high prevalence of healthcare litigation -CMS (medicare/medicaid) now considers pressure ulcers a preventable adverse event & do not reimburse treatment for pressure ulcers acquired during admission

Primary vs. secondary prevention

Primary Prevention: 1. healthy lifestyle behaviors -*PREVENTATIVE; exercising, refraining from smoking/drinking* 2. stress management 3. active social engagement 4. cognitive stimulation 5. immunizations Secondary Prevention: 1. evidence-based *SCREENING* guidelines -ex: screening an older adult for diabetes by checking BG & hgb A1c 2. annual wellness visits -physical exam & labs 3. personalized prevention plan -presenting a diabetic person with a diet plan (can also be considered tertiary bc diet can be a treatment for a diabetic)

Age-related macular degeneration nursing care

Promotion: 1. After age 40 - should have a *dilated eye exam performed every 2 yrs* 2. After age 65 - *eye exam yearly* 3. Supplements/Diet -*Vit C & E, beta-carotene, Zinc* -*Dark green leafy veggies* 4. Smoking cessation 5. Manage HTN and DM 6. Sunglasses 7. Hats 8. Safety eye wear 9. Interventions to utilize remaining vision -*vision will NOT return*

Thin, fragile skin. Teach person to wear long sleeves & protect skin from trauma, especially their arms

Purpura (purple splotches on arms; essentially bruises)

What is a good intervention for pill-rolling with PD?

Put change in a person's pocket and they can constantly manipulate and jingle the change to help with the tremors that they're experiencing.

Glucosamine sulfate is used to:

Reduce joint pain; improve function of knees with OA 1. Often used in conjunction with chondroitin 2. Evidence leans toward supporting efficacy 3. SEs: Gi upset, headache, insomnia, rash, hypoglycemia -*Overall, well tolerated* 4. Contraindications: *Shellfish allergy and glaucoma (increases IOP)* 5. Use with caution with antidiabetics & hypertension

Pressure ulcer risk factors (4) & systemic prevention (5)

Risk factors in older adults: 1. skin changes 2. comorbid illnesses 3. nutritional status 4. reduced mobility Systematic prevention 1. eliminate friction & irritation 2. reduce moisture 3. turning 4. propping 5. promote nutrition

Methimazole (Tapazole) side effects & nursing considerations

SE's: 1. Papular rash 2. *signs of hypothyroidism* (things become SLOW) 3. arthralgia (joint pain) 4. pancytopenia (deficiency of RBCs, WBCs, & platelets) 5. neuropathy 6. drowsiness Nursing Considerations: 1. Assess thyroid function tests 2. *Closely monitor INR with warfarin* -will cause *falsely low INR* 3. *report swelling* of cervical lymph nodes 4. *Give at same time each day and with food.* -*opposite of treatment for hypothyroidism, which is given without food* 5. Contraindicated in pregnancy (category D)

Interventions for depression

SSRIs = first-line drug *Combo of pharm therapy + psychotherapy = BEST treatment for depression* Meds are tailored to specific patient needs; trials of alternate medications and psychotherapy required in many patients

Waxy, raised lesion. No prevention.

Seborrheic keratosis

________________ is the highest expression of one's individual potential and implies inner motivation that has been freed to express the most unique self or the "authentic person"

Self-actualization -an important part of self-actualization is defining life in such a way as to *allow room for continual discovery of self* -*not all people make it to self-actualization stage*

The __________ ___________ model focuses exclusively on the care given between the time that death is first recognized as imminent possibility and until the patient leaves the site of death for burial

Silver hour

AD - Progressively Lowered Stress Threshold model (PLST)

Stressors that may trigger symptoms: 1. Fatigue 2. Change in environment, routing, caregiver 3. Misleading or inappropriate stimuli 4. Demands to perform beyond abilities 5. Pain, illness, depression Care: 1. *Structured to decrease stressors* 2. *Provide safe and predictable environment* Outcomes: 1. Improved sleep 2. less sedatives 3. better nutrition 4. socialization 5. decreased anxiety/agitation 6. care giver satisfaction

Current economic trends & retirement

The Great Recession of 2009+ - stock market suffered, many were laid off, hiring freezes, retirement plans suffered -Many people that were retired went back to work because they lost their 401k or their spouse lost their job -Many nurses came back to work out of retirement -New career paths pursued later in life -Many families currently unable to plan for retirement

CSF analysis - nursing considerations for lumbar puncture

The adult receiving a lumbar puncture should be: 1. side-lying 2. back should be arched to get in between the vertebrae 3. the person who has had lumbar puncture *should lay supine for at least 1 hour after the procedure.* 4. the nurse should be assessing if there is any leakage of CSF post-procedure.

Silver hour - dead PCC goals

The body released to next care provider (funeral home, morgue, etc.) 1. Discharge procedures 2. Maintenance of family/pt. wishes 3. Make sure family knows how to contact funeral home/morgue 4. Walk family to car (this means a lot to people) 5. Need for info and support after death is very important -Create an information page that gives the most important information a family may ask the day after a death.

Gland anterior to the neck crossing the trachea just below the larynx & has 2 main lobes which lie on either side of the trachea is the:

Thyroid gland -produces thyroid hormone (TH) which: 1. Controls metabolic rate 2. Oxygen consumption 3. Energy production The thyroid gland influences physical/mental growth, nervous sytem activity, fluid/electrolyte balance, reproduction, requirements for vitamins, and resistance to infection -Metabolism of fat, protein, & carbs -Control of secretion The secretion of TH is controlled by stimulation & suppression mechanism from hypothalamus, pituitary, & thyroid glands -*Negative feedback mechanism* *Production of TH is regulated by thyroid stimulating hormone (TSH) which is produced in the pituitary gland.* TSH is produced to communicate to the thyroid gland whether it needs to produce TH or not

PD - COMT inhibitors (-capone)

Tolcapone (Tasmar), entacapone (Comtan) 1. Inhibits COMT, which breaks down dopamine -so this med is *preventing the breakdown of dopamine* 2. Used synergistically with levodopa & sinemet 3. Monitor LFTs - *this drug class is hard on the liver* 4. *Interacts with warfarin, so monitor INR closely* 5. *NOT to be used with MAOBIs* Client education 1. Take with food 2. No alcohol or sedatives 3. Interventions to prevent postural hypotension 4. Don't stop abruptly 5. *Report muscle control changes, jaundice, dark urine, & hallucinations* (hallucinations caused by increase in dopamine & can be dangerous)

____________ are 4 times more likely to abuse alcohol

White men -late onset alcohol abuse is associated with illness, retirement, loss of spouse

PVD - venous insufficiency

With chronic venous insufficiency, *blood CAN get to the feet but can't get out, so it becomes congested/stuck in feet.* 1. Outflow problem 2. Causes extremities to be warm, dark red/purple 3. Appears dull gray in those with darker skin 4. Pain is *worse with immobility & improved with elevation.*

Older _________ are the fastest growing segment of the population

Women Social status: -Most likely to live alone *(especially white)* -Women of color often have higher social status within families -Often have extended social network vs men Economic status: -Overall lower than men -*The older woman is more likely to be poor* Health status: -Live longer vs men, therefore *develop more chronic diseases and disability* -Women's health issues receive attention later with research; *women's health issues often studied on men* -"Women's Health Initiative" - promoted enrolling women in research trials -*Higher risk of being without insurance r/t divorce, death of spouse*

Sexual health - biological changes with aging

Women: 1. Menopause 2. Dyspareunia (painful intercourse) from vaginal dryness and thinning of the vaginal tissue Men: 1. Erectile dysfunction 2. Refractory period extended between episodes of intercourse

An older client was told by the physician that their cancer is terminal. The client understand the meaning of this when they state which of the following? a. "now I must have surgery to remove the tumor" b. "my cancer can't be cured" c. "the chemo will need to be increased" d. "I'm on the way to recovery"

b. "my cancer can't be cured"

The nurse assists an older client in reaching a state of self-actualization by: (select all that apply) a. instructing the client to laugh during severe pain b. encouraging them to volunteer c. positively reinforcing courageous behaviors d. allowing them to discuss their life-meaning

b. encouraging them to volunteer c. positively reinforcing courageous behaviors d. allowing them to discuss their life-meaning

Which of the following are adjuvant therapeutic palliative care activities? (select all that apply) a. dialysis b. music c. guided imagery d. meditation e. pain management

b. music c. guided imagery d. meditation e. pain management

An older client informs the nurse that the name brand synthroid is no longer covered by insurance and will need to start the generic. How should the nurse respond? a. you can never switch to levothyroxine b. you can change without any worries c. you will need to see your provider to switch d. older adults should take only synthroid

c. you will need to see your provider to switch

Mini-cog

*Also used to assess for dementia* -Equivalent to MMSE -*Combination of MMSE and CDT* -Short-term memory and executive function -*Must hear, hold pencil, write numbers* Directions: Give pt paper to do CDT and begin with *asking them to remember 3 unrelated words* (ball, sky, shoe). Wouldn't say something like shirt, pants, tie because those things are related & can be remembered more easily. Then immediately go into CDT where you have them draw a time. After they've drawn the clock, say "tell me those 3 words again" Scoring: -points awarded for recalled words first; *all 3 remembered = dementia unlikely.* -*None remembered = dementia likely.* -normal: all numbers/hands correct -abnormal: any errors

Assessment of spiritual resources & concerns

*Ask to all patients upon admission* 1. Does your religion/spirituality provide comfort or stress? (Ask to explain in what ways spirituality is comfort or stressor) 2. Do you have religious or spiritual beliefs that might conflict with health care or affect health care decisions? (Ask to identify any conflicts) 3. Do you belong to a supportive congregation or faith community? (Ask how faith community is supportive) 4. Do you have any practices or rituals that help you express your spiritual or religious beliefs? (Ask to identify or describe practices) 5. Do you have spiritual needs you would like someone to address? (Ask what those needs are and whether referral to spiritual professional is desired) 6. How can we (health care providers) help you with your spiritual needs or concerns?

Proper method of administering meds via tube (8)

1. Liquid form preferred 2. Crushed well 3. Dissolved in appropriate amount of solvent (warm water) 4. HOB 30 or higher; check placement; assess for aspiration 5. Flushing 6. *Hold feeding 30 min before; 30 min after* 7. *Prepare each med separately and give separately* 8. Drug-drug interactions possible if mixed together outside of stomach

3 stages of Alzheimer's disease

1. Preclinical -Early cognitive decline *before overt symptoms are present* 2. Mild Cognitive Impairment -Amnestic MCI (isolated to memory loss) -Multiple domain MCI -Single non-memory MCI -*Approximately 12% of persons over age 70 have MCI and are 3-4 times more likely to develop AD* 3. Alzheimer's dementia -*Most advanced stage* -*Multiple deficits present*

Extrapyramidal side effects (4)

1. dystonia: involuntary muscle contractions (often face, neck) 2. akathisia: compulsion to be in motion, restless 3. parkinsonian symptoms: difficulty walking, tremors 4. tardive dyskinesia: abnormal facial movements, non-reversible

Opioid analgesics to promote comfort (7)

1. *Demerol (meperidine) contraindicated in older adults* 2. Begin with short acting low dose medications and titrate to response and side effects 3. Age-related changes may produce a greater analgesic effect, a higher peak, and longer duration of effect 4. Sedation, respiratory depression, and impaired cognition often occur 5. Increased risk for falls and injury -*instruct pt to ask for help before getting up* 6. Bowel regimen necessary to prevent constipation -*should be used with stool softeners & laxatives* 7. Pain management consult for unrelieved pain

Limited access to safe transportation contributes to: (3)

1. *Social isolation, decreased self worth, & depression* -not socializing with others can have a huge impact on mental health 2. Poor nutrition 3. Neglect of health -*inability to go to grocery store as often as needed results in buying foods that will last & aren't necessarily healthy* -*Transportation is critical for the older adult to remain independent & functional* -Area agencies can provide information and resources to help older adults with limited transportation accessibility

Fluid quality to maintain hydration

1. *Water is best: bulk of fluid intake should come from water* 2. Second: milk, fruit juice, & non-salty soups are ok; not as good as water but still hydrating. 3. Coffee and tea: not so great, have diuretic effects but can still be hydrating. Definitely should not be bulk of person's fluid intake. 4. Alcohol should NEVER be recommended for hydration purposes; it's dehydrating & has a diuretic effect

Cultural variations & abuse - Asian/pacific islander

1. *ability to endure violence as a symbol of strength and honor* 2. not familiar with terms of abuse; instead use terms "sacrifice" and "suffering" 3. *psych. Abuse considered the worst* 4. *strong belief in filial duty to care for parents may result in excessive burden* 5. defined only within a family setting 6. *unacceptability to express emotions*

Cultural variations & abuse - Asian Indian

1. *children leaving family home may be considered a form of elder abandonment* 2. *oldest son handles finances*, without question 3. as age is venerated, physical abuse very uncommon

HIV & older people

1. 1.25 million people living with HIV. In 2011, 37% were 50 and older. In 2015, half were over the age of 50. In 2020, there is estimated that 70% of people with HIV will be 50 or older. -This doesn't mean that people who are older are contracting HIV, this means that people with HIV are living longer. 2. *Compromised immune system makes older adults more susceptible* to HIV or AIDS than are younger persons 3. Contrary to popular belief, HIV/AIDS in elderly population is *not result of blood transfusions alone nor is it confined to gay population* 4. *Older women at high risk for infection due to normal changes in vaginal tissue* 5. *Many symptoms mimic other disease conditions* -Virus may be in late stages by time of diagnosis 6. Medicare in 2010 began covering HIV screening for high risk individuals -*All adults should have an HIV test at least once* 7. Educational materials need to be developed for older adults

Examples of health disparities - Mexican Americans

1. 2 times more likely to have diabetes mellitus (DM) 2. *Get 36% fewer prescriptions after myocardial infarction* -factors contributing to this may include access to healthcare, language barriers, culture

Examples of health disparities - African Americans

1. 50% more likely to have stroke -Transient ischemic attack: *62% fewer get anticoagulation* 2. 50% more likely to die of stroke 3. 20% more likely to die of heart disease 4. 1.5 times more likely to have hypertension 5. 2.5 times more likely to have diabetes 6. 30% more likely to have diabetes-related amputations

Herbs & supplements background

1. 50-60% of older adults use supplements or herbs -vitamins, non-herbals, & herbs 2. Hope to prevent illness, promote & maintain health, treat a health problem, & dietary supplementation 3. Often believe that they are natural & safe 4. Higher use when unsatisfied with medical care 5. *Grossly underreported*

CV Drugs

1. ACE inhibitors (-pril) -*major complication/adverse effect is angioedema* -*common side effect is a cough*; person can be changed to an ARB 2. ARB's (-sartan) -ACE inhibitors & ARBs are similar; they just work differently in the cascade. *Both don't work as well in African Americans.* Often African Americans with HTN are started on a CCB or diuretic first, but a person who is white might be started on an ACEI. -*African American's have a higher risk of side effects & adverse reactions to ACEI. ARB's don't have as many side effects & complications* -*Person with CKD will not be on an ACEI or ARB bc they are renal toxic.* -However, *they'll continue to use ACE inhibitors if a person has renal insufficiency to increase the blood flow to the kidneys* bc ACEIs prevent the conversion of angiotensin I to angiotensin II. Angiotensin II is a vasoconstrictor; if constriction is prevented, blood flow can get to kidneys 3. Thiazide diuretics -*try to avoid diuretics. NOT 1ST LINE IN OLDER ADULTS* 4. Beta blockers (-olol) -decrease the HR; *must assess HR along with BP before administering*. -Won't hold med *unless the HR is less than 60 bpm* 5. Nitrates (nitroglycerin) -older men use meds for ED & meds used for that cause vasodilation. Nitrates also cause vasodilation so there is *risk of syncope, hypotension, & injury* when these meds are used together. -ALWAYS ASSESS FOR THIS -Doesn't mean that person who had viagra 2 days ago & is now having CP can't have a nitrate, that med has processed off. *Just should NOT be given within a close period.* 6. Calcium channel blockers (-dipine, norvasc) -used for HTN; *avoid with HF* *ASSESS BP BEFORE ADMINISTERING ANY OF THESE*

Risk factors for delirium

1. Acute illness 2. Infections -especially respiratory or urinary tract 3. Medications 4. Invasive equipment 5. Hypoxemia & metabolic disturbances 6. Dehydration 7. Alcohol or drug abuse 8. Sensory impairments, functional deficits 9. Unrelieved pain 10. Surgery 11. Hip fracture 12. Cognitive impairment (dementia) 13. Electrolyte imbalances, fluid overload, nutritional deficiencies 14. Prolonged bleeding, anemia 15. Transfusion reaction 16. Emergency admission or admission from a LTC facility 17. Prolonged emergency dept stay (>12 hrs) 18. Use of restraints 19. Prolonged immobility 20. ICU stay

Use of adjuvant medications in pain management

1. Adjuvant drugs -Tricyclics for neuropathic pain -Avoid drugs that precipitate or potentiate extrapyramidal symptoms -Avoid tranquilizers that produce sedation and have long half-life; drugs with short half-life are more suitable 2. Corticosteroids 3. Topical agents 4. Muscle relaxants

Older population projections (3)

1. African American: 4 million in 2014 (9% of older population) & *projected 12 million by 2060* 2. Hispanic (of any race): 3.6 million in 2014 (8% of older population) & *projected 21.5 million by 2060 (22% of older population)* 3. Non-Hispanic Asian: 1.9 million in 2014 (4% of older population) & *projected 8.5 million by 2060 (9% or older population)*

Geropharm background

1. Age 65+ = largest consumer of medications -12% of population -1/3 of medication consumers -½ of OTCs 2. 94% take rx meds 3. 46% take OTCs 4. 53% take supplements Most common Rx meds for older adults: CV, diuretics, nonopioid analgesics, anticoagulants, antiepileptics Most common OTCs meds: GI, analgesics, cough products, eye washes, vitamins

Cross-linkage theory (4)

1. Aging is a product of accumulated damage from *errors associated with cross-linked proteins* 2. Initiated by blood glucose in process of glycosylation or glycation (cellular glucose attaches to protein) 3. Cross-linked proteins (i.e. collagen) become stiff and thick—*evidenced by stiffened joints and decreased skin elasticity* 4. Collagen - Joints, skin, lungs, arteries, tendons -high amount of collagen keeps skin elastic; amount lowers as you age

Neurological communication difficulties

1. Anomia -*Difficult word retrieval* 2. Aphasia -Impairment in *processing language* -*Ability to speak and/or understand* -Intelligence not affected -Caused by damage to brain (CVA or head trauma; often left side) 3. Dysarthria -Impaired *ability to articulate speech* -*weakness/ incoordination of speech muscles* -Damage to neurological system (CVA, head injury, parkinson's, multiple sclerosis)

5 types of grief

1. Anticipatory grief: response to real or perceived loss before it occurs -person may start to slowly remove themselves from a loved one diagnosed with a terminal illness to make it "easier" when the loss actually occurs 2. Acute grief: Grief when an unexpected or sudden loss has occurred 3. Chronic grief: grief that is ongoing. Can turn into complicated grief if grieving is not done properly. 4. Complicated grief: can't move on or work through grief 5. Disenfranchised grief: loss can't be openly acknowledged -ex: person is in jail and is killed while in jail. They may have committed a horrible crime like murder but they still have family and loved ones. The loved ones grief over the death may not be validated because they were a criminal.

GU assessment (9)

1. Assess renal function, particularly in acute/chronic illness 2. Monitor orthostatic BP -*traditional signs of dehydration are not as specific in elderly; orthostatic bp can be a good indicator* 3. Assess for dehydration, volume overload, electrolyte imbalances, proteinuria 4. Determine source of fluid/electrolyte imbalance. Monitor labs - creatinine clearance 5. *Assess choice/dose/need for nephrotoxic agents (incl. aminoglycoside antibiotics, radiocontrast dyes) and renally excreted medications* 6. Palpable bladder after voiding due to retention 7. Assess for urinary incontinence, UTI 8. Assess for abnormal urine stream with BPH -need to watch for dribbling 9. Assess fall risk in nocturnal or urgent voiding

Eye assessment (4)

1. Assess visual acuity (under various light conditions), color vision 2. Note difficulties in funduscopic exam 3. Evaluate impact of vision limitations on driving (day & night), ambulation, safety, social interactions 4. Appraise home environment for hazards, lighting

Nursing responsibilities to enhance healthy intimacy & sexuality in older adults

1. Assessment of any medical conditions or medications associated with poor sexual health 2. Counseling for older adult to adapt to natural physiological changes or body-image alterations from surgical procedures

3 stages of grief

1. Beginning -physical & psychological manifestations 2. Middle -day to day functioning affected 3. End -griever emerges refocused & adjusted -griever has found a new normal or has adjusted to the grief

AD - Need-Driven Dementia-Compromised Behavior Model (NDB)

1. Behaviors have meaning and are an attempt to communicate 2. *Interaction between background and proximal factors* -Background: cognitive changes, gender, ethnicity, culture, education, personality, responses to stress -Proximal: physiologic needs food, pain relief, mood, physical environment (light, noise) Care: 1. Manipulate proximal factors 2. Maximize strengths 3. Minimize limitations of background factors *ex: impaired sleep patterns - focus on things that can be changed*

Antixiolytics

1. Benzodiazepines -end in "am" -highly effective -fast onset but long half life -side effects include drowsiness, dizziness, memory & cognitive deficits -*FALL RISK* -Toxicity: *excessive sedation*, confusion, disorientation, agitation, wandering (signs of dementia) 2. Buspirone (BuSpar) -nonbenzodiazepine -taken daily -no effect until about 1 week -*teach pt that it may take a while for it to become effective*

Cultural beliefs about health, illness, & treatment

1. Biomedical -Western medical paradigm -Focus on disease/abnormalities in body systems 2. Magico-religious -God or supernatrual forces cause disease -Good health is a blessing or reward 3. Naturalistic or holistic -Health is a sign of balance -Illness occurs with imbalance or disharmony

Programmed aging (3)

1. Body/cells are *designed to age* (predictable) 2. Suggest that *aging is the result of predictable cellular death* 3. Cells and organisms have a genetically predetermined lifespan known as the "Hayflick limit" or *biological clock*

Dehydration 4 categories

1. Can drink -able to drink, don't have any problems drinking fluids -just don't know how much they should be drinking/what's adequate -Possible cognitive impairment causing them not to remember to drink -Need to encourage & make fluids accessible 2. Can't drink -Physically incapable of ingesting or accessing fluids; may have dysphagia or had a stroke -Need to focus on dysphagia prevention -*Assess swallowing & do a swallow evaluation*; collab with a speech/language pathologist -Teach safe drinking techniques/ interventions for dysphagia -Person who can't drink may also have a peg tube & are reliant on nurses to get them fluid. When reliant on someone, there's a big risk you won't get enough. This may be a situation where you would get an order for water 3. Won't drink -*Highest risk for dehydration* -Able to drink but refuses/limits intake for some reason -*may be due to fear of incontinence or cognitive impairment* -for fear of incontinence, providing teaching (scheduled voiding, kegel exercises) 4. End of life -Terminally ill -could be any of the previous 3 (can, can't, or won't drink) -*Must refer to advanced directives with regard to hydration wishes* -if person is actively dying or we expect them to die very soon, urinary output is not a priority; there are no life saving measures. Keep in mind that the goal may not be to rehydrate the person.

3 Temperature vulnerability factors

1. Caretakers/family -Monitor individual who has cognitive or physical limitations that affect ability to respond to changes in temperature 2. Economics -When an older person *cannot afford proper heating or air conditioning* -*major cause of temp vulnerability* 3. Safety concerns might prompt older adults to bolt doors and windows, creating unsafe temperature in home environment -unable to open up windows to let a breeze in, creating higher temps; also unsafe if unable to open window if there's a fire in the house

Wear and tear theory (4)

1. Cellular errors a result of *"wearing out" over time from continued use* 2. A progressive decline in cellular function or increased cellular death 3. Cells *aggravated by internal & external stressors*: the sun is an external factor responsible for aging of the skin 4. Cells destroyed by mechanical and chemical injury

Essential factors in choosing a LTC facility

1. Central focus: residents and families are the central focus of the facility 2. Interaction: -staff members are attentive and caring -meaningful activities are provided on all shifts to meet individual preferences -staff members talk to cognitively impaired residents; cognitively impaired residents are involved in activities designed to meet their needs -staff members do not talk down to residents, talk as if they are not present, ignore yelling or calling out -families are involved in care decisions and daily life in facility 3. Milieu: -calm, active, friendly -presence of community, volunteers, children, plants, animals 4. Environment: -no odor, clean, and well-maintained -rooms personalized -private areas -protected outside areas -equipment in good repair 5. Individualized care: -restorative programs for ambulation, ADLs -residents well dressed and groomed -resident and family councils -pleasant mealtimes, good food, residents have choices -adequate staff to serve meals and assist residents -ethnic food preferences available 6. Staff: -well-trained, high level of professional skill -professional in appearance and demeanor -RNs involved in care decisions & care delivery -active staff development programs -physicians and advanced practice nurses involved in care planning and staff training -adequate staff (more than minimum required) on each shift -low staff turnover 7. Safety: -safe walking areas indoors and outdoors -monitoring of residents at risk for injury -restraint appropriate care, adequate safety equipment and training on its use

2 medications for AD

1. Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) -Block acetylcholinesterase -Work to slow the progression, not reverse -*Teach patient & family that there will NOT be an improvement in cognitive function* - need to have realistic expectations -Start with *low doses and titrate up* -*GI distress: most common side effect*; often seen in the beginning. Can resolve just by taking it with food & will go away the longer the person has been taking it -*Reassess every 6 months* 2. Glutamate receptor blocker (memantine) -Blocks glutamate -*Has more neurological SEs: dizziness, HA, confusion, somnolence* -Antidepressants often required while taking these drugs -*Try to avoid antipsychotics: NEVER use as the treatment for behavioral issues associated with dementia*

Age can be: (4)

1. Chronological - # of years lived 2. Biological - age of organ systems 3. Psychological - how old one feels 4. Social - roles and relationships *age is a SUBJECTIVE term*: varies with time, place, cohort and perception

9 signs & symptoms of depression in older adults

1. Comorbid medical conditions strongly related to depression in older people 2. More somatic complaints - physical symptoms 3. Hypochondriasis - Constant complaining & criticism 4. Decreased energy and difficulties completing ADL's 5. *Social withdrawal* 6. Decreased libido 7. Preoccupation with death 8. Memory problems -can often be missed bc of the normal changes associated with aging 9. Strong association of depression with dementia

Cardiovascular 4 interventions

1. Complete assessment of all risk factors and existing disease -comorbidities such as hypothyroidism can exacerbate HF; hyperthryoidism can exacerbate HTN. Look at each disease & see how each one can affect the other 2. Lifestyle changes 3. Medication regimen tailored to specific disease process and patient needs -Education -Referral for financial assistance with medications if needed 4. Focus on *symptom management and prevention of exacerbations* of disease

RA interventions

1. Complete physical and laboratory assessment -labs can be drawn to diagnose RA (rheumatoid factor), but *cannot be diagnosed just based on labs. Must have physical exam & history too.* 2. *Pharm therapy/pain mgmt with DMARDs (disease-modifying anti-rheumatic drugs): methotrexate* -*immunosuppressant* that is sometimes used for cancer -side effects & complications are immunosuppressant effects -mouth sores, signs of anemia (fatigue, pale), signs of liver problems (dark urine, N/V), easy bruising & bleeding, black stools 3. Exercise and physical therapy 4. Environmental modifications 5. Assistive devices -*braces should be used VERY cautiously.* When a person has RA & is braced or put in a splint because of pain, it GREATLY *increases the risk of complication like contractures. Joint can contract and become immobile permanently because of chronic splinting*. BE CAREFUL WITH THESE ASSISTIVE DEVICES

Female sexual dysfunction

1. Considered persistent impediment to person's normal pattern of sexual interest, response, or both 2. Influenced by culture, ethnicity, emotional state, age, previous sexual experiences, as well as changes in sexual response with normal aging 3. Causes: -Physiologic changes -Menopause/hormonal changes 4. Water soluble lubricants, low-dose estrogens introduced into the vagina may also help restore tissues and restore lubrication -hormone replacement therapy can also be used, but this is controversial because older women are at higher risk for developing cancer and if a person is receiving synthetic hormone therapy, it can actually feed the cancer and make it worse

Pain in cognitively impaired elders (3)

1. Consistently untreated or undertreated for pain 2. Careful observation and caregiver reports need to be used if person cannot reliably communicate pain 3. Non-verbal expressions of pain include: -Behavioral changes: restlessness/agitation or reduction in movement, repetitive movements, physical tension, unusually cautious movements -Changes in ADL's: sudden resistance to help from others, decreased appetite & sleep -Vocalizations: groans, moans, cries, increases or decreases using vocalizations -Physical changes: pleading expression, grimacing, pallor or flushing, diaphoresis, *increased pulse, respirations, or BP*

Skin changes 9 CM

1. Cool, pale, dry skin 2. Increased fragility, wrinkling, tenting, sagging (breasts & abdomen with risk of yeast infections) 3. Decreased elasticity, turgor, wound healing, and perspiration with *reduced ability to maintain temperature* 4. Risk of skin tears, ecchymosis, dermatitis, pressure ulcers, dehydration 5. Increased senile lentigines (flat brown spots), neoplasms 6. Decreased sensation with risk of injury 7. Decreased fat, muscle tone of feet affecting ambulation 8. Graying, dry, thinner hair with facial hair alterations in men & women 9. Thick, brittle, easily split nails with slow growth & risk of fungal infections

Signs & symptoms of approaching death with interventions

1. Coolness from diminished peripheral circulation to increase circulation to vital organs -socks, light cotton blankets or warm blankets if needed; don't use electric blanket 2. Increased sleeping for conservation of energy -respect need for increased rest; inquire as to their wishes regarding timing of companionship 3. Disorientation from metabolic changes -identify self by name before speaking to pt; speak softly, clearly, & truthfully 4. Fecal and/or urinary incontinence from increased muscle relaxation -change bedding as needed; use bed pads; avoid indwelling catheters 5. Noisy respirations from poor circulation of body fluids, immobilization, & the inability to expectorate -elevate head with pillows or raise HOB; gently turn head to the side to drain 6. Restlessness from metabolic changes & relative cerebral anoxia -calm the pt by speech & action; reduce light; gently rub back, stroke arms, read aloud, play soothing music; don't use restraints 7. Decreased intake of food & fluids bc of body conservation of energy for function -provide nutrition within limits expressed by patient or in advanced directive; semisolid liquids easiest to swallow; protect mouth/lips from dryness 8. decreased urine output r/t decreased fluid intake & decreased circulation to kidney -no interventions needed 9. altered breathing pattern r/t metabolic & oxygen changes -elevate HOB; speak gently to pt

Characteristics of self actualization

1. Courage—Conquer fear in face of difficulties 2. Altruism—Helping others & sense of being needed provides meaning of life 3. Humor—Be careful...Not always appreciated 4. Continuous moral development—Love (Plato) & Intellect (Aristotle)

Creativity & involving older people in arts

1. Creative arts for elderly 2. Creative arts for people with dementia 3. Creative arts and theater 4. Creative expression through music, poetry, dance -Consider access issues such as cost, transportation, time of day -Seek local and national funding -Publicize -Orient elders interested in participating -Provide incentives for participating: awards, receptions, refreshments

Reducing health disparities

1. Cultural awareness -self-level: requiring self-understanding of one's experiences and values; understanding own beliefs and values so that you can approach those that are different with an open mind -Ability to work with and build relationships with a member from another cultural group -Recognition of factors beyond culture, such as health, safety, and poverty, that affect members of a cultural group 2. Cultural knowledge -Both what *nurse brings to caring situation* and *what nurse learns* about older adults, their families, their communities, their behaviors, and their expectations -Essential knowledge includes elder's way of life (ways of thinking, believing, acting)

3 Nervous system changes

1. Decrease in neurons, brain size, neurotransmitters 2. Slowed nerve impulse conduction 3. Decreased peripheral nerve function

7 Eye changes

1. Decreased orbital fat, muscle elasticity, tear production -orbital fat is fat surrounding the eye (keeps eyes where they're supposed to be; *decrease in fat may make eyes appear more sunken*) 2. Decreased corneal sensitivity, reflex; increased translucency, flattening 3. Loss of pigment in iris, smaller pupil 4. Increased vitreous gel debris 5. Decreased aqueous humor secretion with reduced cleansing of lens & cornea 6. Ciliary muscle atrophy 7. Lens less elastic, denser, yellow with decreased light passage

7 Skin changes

1. Decreased subcutaneous fat, interstitial fluid, muscle tone, glandular activity, sensory receptors 2. Collagen stiffening 3. Reduced blood supply & capacity for repair 4. Capillary fragility 5. Cumulative androgen effect 6. For hair - decreased melanin & follicles 7. Reduced blood supply to fingernails - may cause fingernail thickening or thinning depending on the person; risk of infection

9 GI changes

1. Decreased thirst perception -may take losing up to 5-10% of circulating blood volume before an older adult realizes they're dehydrated 2. Decreased saliva with dry mucosa, bone loss -*decreased saliva --> decreased absorption of things like calcium* -*dry mouth = decreased appetite & increases risk of mouth cracking & infection* 3. Atrophy of taste & olfactory receptors -complain that nothing tastes good anymore; *results in malnutrition & electrolyte imbalances* 4. Decreased esophageal motility & lower esophageal sphincter pressure -*higher risk for GERD & aspiration* 5. Decreased stomach motility; mucosal atrophy -food remains in stomach longer --> *risk for aspiration* -mucosal atrophy --> decreases secretions & mucosal lining --> *risk of peptic ulcers* 6. Decreased small intestine motility, villi, & digestive enzyme secretion -*villi purpose is to increase surface area for absorption*; villi flatten out & shrink, *putting older adults at risk for malnutrition* 7. Decreased large intestine blood flow, motility, & defecation sensation -water absorption occurs in large intestine when it is vascularized -decrease in vascularization --> *risk of dehydration & constipation* 8. Decreased liver size, blood flow, enzymatic metabolism of drugs; increased biliary lipids -*increased sensitivity to alcohol, altered drug metabolism, & risk of hyperlipidemia/high cholesterol* 9. Decreased pancreatic reserve, enzymatic & hormonal secretory cells -*risk of hypoglycemia* bc of decreased glucagon -*risk of diabetes* bc of decreased insulin

Types of dementia

1. Degenerative dementia -Alzheimer's disease (AD): 50-70% of all dementias; *most common* -Parkinson dementia (PDD) -Dementia with Lewy bodies -Frontotemporal lobe dementia 2. Vascular cognitive impairment -Vascular dementia: can happen after a person has suffered from a stroke; caused by a lack of blood flow to the brain that results in loss of brain function -Mixed primary neurodegenerative disease and vascular dementia 3. Other dementias -Creutzfeldt-Jakob disease (very uncommon) -HIV-related dementia: Those in the later stages of AIDS can have HIV-related dementia from the effect of the virus on the brain.

Who will care for an aging society?

1. Demand is critical for gerontological nurses and other health professionals prepared to deliver care to growing numbers of older people 2. Growing concern is lack of adequate staffing, particularly professional nurses, in nursing homes -*RNs supervise care in LTC facilities while LPNs or CNAs are responsible for providing direct care & lack the professional training to care for older adults* Utilization of Care: 1. Older pts are 63% of pts with cancer 2. Older pts are 60% of visits to cardiologists 3. Older pts are 53% of visits to urologists -disproportionate to younger adults & have more problems that require them to visit these providers

Assessment of anxiety in older adults

1. Difficult to diagnose in older adults 2. Denial 3. *Coexisting medical conditions can mimic anxiety* 4. Common side effect of certain drugs 5. Drug and alcohol withdrawal also cause anxiety symptoms When assessing an older adult with anxiety, you may not see them experiencing anxiety in forms of nervousness, being on edge, or jittery. *The older adult may just simply withdraw and be more quiet*

PD 3 interventions

1. Early assessment and symptom management 2. Surgical procedures -Ablation (focuses on area of brain that produces acetylcholine) -Deep brain stimulation -Stem Cell transplantation (experimental) 3. *Drug therapy focuses on mimicking or slowing dopamine breakdown* -some people with PD don't like the meds; have a lot of side effects & *sometimes have the same effects as the disorder*

2 types of Alzheimer's disease

1. Early onset (between ages 30-60) -Affects about 5% of persons with AD -*Results from genetic mutations of three genes* -Genetic testing available for at risk individuals 2. Late onset (after age 60) -*Does not run in families* -Probable combination of lifestyle, environmental factors, and genetic mutation; *thought to be caused by unstable chronic conditions* (HTN, diabetes, etc.)

Reproductive changes implications & nursing interventions (2)

1. Educate on STD prevention -older adults are at *higher risk for developing a STD bc of pH changes & vaginal wall thinning* 2. Lubricants for vaginal dryness

Hearing changes nursing interventions

1. Educate on regular auditory evaluation, safety if hearing loss 2. Encourage social interaction if isolated from hearing loss 3. *Speak in low toned voice*

On Lok Program of All-Inclusive Care for the Elderly (PACE)

1. Ensure access to interpreter if needed 2. Programs reflect the diversity of participants 3. Consider mono-cultural facilities when population demographics warrant 4. Employ staff who reflect diversity of residents/clients

Promoting healthy aging: 6 implications

1. Experience of pain is multifactorial with physical, psychological, and spiritual components 2. Pain is subjective; unique to each person 3. Careful assessment of presence or absence of pain is possible regardless of cognitive status of person 4. It is never acceptable to fail to treat pain to the extent possible 5. Western and complementary therapies both work together to manage pain 6. Frequent qualitative and quantitative reevaluation of perceived pain is necessary to provide adequate pain relief and promote patient comfort

Eye changes 12 CM

1. Eyes dry & receded with limited upward gaze 2. Risk of ectropion, entropion, conjunctivitis, infection, senile ptosis, artifactual visual fields deficit, arcus senilis; risk of corneal abrasion 3. Blurred vision from scattered light rays 4. Decreased visual 5. Vitrious floaters --> webs in vision field 6. Decreased accommodation & near vision (presbyopia: age-induced vision loss) 7. Decreased peripheral vision 8. Impaired light/dark adaption, color discrimination 9. Decreased night vision, altered depth perception 10. Need for more light to see 11. Difficulty in fundoscopic exam due to smaller pupil 12. Cataracts, Narrow-angle glaucoma

2 General assessment tools

1. FANCAPES *F*luids *A*eration (oxygenation) *N*utrition *C*ommunication *A*ctivity *P*ain *E*limination *S*ocial skills 2. SPICES *S*leep disorders *P*roblems with eating/feeding *I*ncontinence *C*onfusion *E*vidence of falls *S*kin breakdown -*Not scored; yes or no answers.* *Purpose is to gather a baseline assessment & go further with it* using more specific assessment tools according to pt's answers

13 Consequences of untreated pain

1. Falls and other accidents 2. Functional impairment 3. Slowed rehabilitation 4. Mood changes 5. Increased health care costs 6. Caregiver strain 7. Sleep disturbance 8. Changes in nutritional status 9. Impaired cognition 10. Increased dependency and helplessness 11. Depression, anxiety, fear 12. Decline in social and recreational activities 13. Increased health care utilization and costs

Interventions to improve nutritional status

1. Family involvement when possible 2. Use of nutritionally dense supplements with medication pass 3. Restorative dining rooms 4. Consideration of ethnic food choices 5. Easy access to refreshment stations with juices, water, and healthy snacks 6. Liberal diets 7. *Finger foods* -*good for those with alzheimer's who can't sit still. They're able to walk around & eat* 8. Visually appealing pureed foods 9. Establish routine for meals and snacks consistent with accustomed eating schedule 10. Incorporate favorite foods, especially nutritionally dense foods and finger foods 11. Visual cueing and hand-over-hand assistance as needed 12. Appropriate utensils and dinnerware 13. Offer fluids in between bites of food 14. Eliminate distractions 15. Allow time for older person to enjoy and complete meal

Hope-promoting activities

1. Feel warmth of sun 2. Share experiences children are having 3. See crystal blue of sky 4. Enjoy garden or fresh flowers 5. Savor richness of black coffee at breakfast 6. Feel tartness of grapefruit to wake up taste buds 7. Listen to symphony 8. Watch activities of animal in tree outside window 9. Benefit from each encounter with another person 10. Write messages to grandchildren, nieces, nephews 11. Study favorite painting 12. Build highlights into each day such as meals, visits, Bible reading 13. Keep journal 14. Write letters 15. Make tape recording of life story 16. Have hope objects or symbols nearby 17. Share hope stories 18. Focus on abilities, strengths, past accomplishments 19. Encourage decision making about daily activities to foster sense of control 20. Extend caring and love to others 21. Appreciate expressions of caring concern 22. Renew loving relationships

Fecal impaction nursing management

1. First prevent - *prevention of constipation is the most important thing for nurses to do.* 2. Removal of impaction -Digital removal of hard stool from rectum -Use copious lubricant -May take several days -Don't dis-impact too much -Often very painful If person has large impaction, evacuation of stool may actually cause problems & the person can vagal down (vagus nerve becomes stimulated & person becomes bradycardic & hypotensive)

AD requires ongoing assessment of:

1. Functioning 2. cognitive status 3. co-morbid conditions 4. behavior 5. medications 6. living arrangements 7. safety

Therapeutic communication with older adults

1. Give more time/Silence -Possible slowed thought process -Must sort through many years of memories to answer 2. Closed-ended questions -*Not considered therapeutic, but needed to get specific answers* -ex: asking, "do you have diabetes?" -*If person has the ability to easily elaborate, they may feel put on the spot* 3. Open-ended questions -Allow for client elaboration -May be difficult for some; *not sure what you are asking/want to please* 4. Proper body positioning 5. Seek clarification 6. Pay attention to non-verbals

10 characteristics of individuals with a high degree of gerotranscendence

1. Have high degrees of life satisfaction 2. Engage in self-controlled social activity 3. Experience satisfaction with self-selected social activities 4. Social activities not essential to their well-being 5. Midlife patterns and ideals no longer prime motivators 6. Demonstrate complex and active coping patterns 7. Have greater need for solitary philosophizing 8. May appear withdrawn when engaged in inner development 9. Have accelerated development of gerotranscendence fomented by life crises 10. Feel shifts in perception of reality

Hyperthermia 3 stages

1. Heat fatigue -pale, sweaty, elevated HR -*normal temp* -typically when an older person has heat fatigue it's *missed & overlooked* as just being hot, *but it can quickly lead to heat exhaustion* 2. Heat exhaustion -cramping, *cool/clammy,* tachycardia, thirsty, *altered mental status*, nausea -*temp normal or mild elevation* 3. Heat stroke = MEDICAL EMERGENCY with high mortality in older adults -*defined as temp higher than 104* -start to have *cellular & organ damage*; body is not compatible with a temp of 104 -flushed, *HOT & DRY*, tachycardia, *mental status change*, hypotension, hyperventilation (mechanism to lower body temp)

PD nursing care - teach exercises (9)

1. Lift toes when walking 2. Widen legs while walking 3. Small steps while looking forward 4. Tight corner manipulation -*means putting the person in a corner & telling them to get themselves out.* For a person with PD, it takes a lot of effort & practice to get out of a tight situation 5. Swing arms with walking to improve balance and ROM 6. Carry bag to counterbalance is necessary -*backpack can help straighten out stooped gait or posture. If person is not standing upright when walking there is a higher risk of falling bc they're not seeing what's in front of them as easily* 7. Facial exercises 8. Read aloud -*helps them to better articulate words* 9. Speak slowly with purpose and concentrated articulation

Fall, balance, & gait assessment

1. Hendrich II -*includes the get up & go test*: person's ability to independently rise from a chair with not a lot of effort, stand up, walk, & then come back to the chair. -assesses how many attempts it takes; are they successful, does it take them a couple of times of rocking to get out of the chair, or are they unable to rise without assistance -*objectively assesses the older adults risk for falling* -males get a point just for being a male. *Older men are more likely to fall than women* 2. Tinetti Balance & Gait -*test includes nudging patient to assess their balance*; if pt does have an issue with balance, they will most likely fall over so this *should be done as a team* -assessment typically done by physical therapy -*if score is low, pt has a high risk for falls*

Thyroidectomy 6 complications

1. Hypothyroidism 2. Hypoparathyroidism -parathyroid glands are smaller glands attached to the thyroid & produce parathyroid hormone (PTH) -*PTH helps to regulate calcium; if damaged or taken out during surgery, person is at risk for hypocalcemia* 3. Hypocalcaemia and tetany -*closely monitor for this & assess for signs of muscle rigidity* 4. Vocal cord paralysis -due to area of the thyroid 5. Resp obstruction 6. Thyroid Storm (Thyrotoxicosis) -*can be life-threatening* -exaggerated symptoms of hyperthyroidism -*causes hyperthermia; core body temp of 102-106.* Human body can't tolerate temp over 104 -*can cause organ damage & seizures; high BP & HR*

3 components of memory

1. Immediate recall (minutes, hours ago) 2. Short term memory 3. Remote or long-term memory -In older adults, *long-term memory is usually more intact, while the immediate recall is impaired and is the most affected.*

4 complications of constipation

1. Impaction which can lead to an obstruction --> bowel perf --> sepsis 2. Increase in falls 3. Delirium, change in mental status 4. The more constipation a person has over their lifetime, *the higher the risk for bowel cancer*

GI changes 12 CM

1. Impaired digestive ability with possible food intolerances 2. Risk of dehydration, electrolyte imbalances, poor nutritional intake 3. In mouth, risk of gingivitis, tooth loss with chewing impairment 4. Impaired perception of taste (also with many drugs) & smell 5. Risk of dysphagia, hiatal hernia, aspiration 6. Delayed emptying of stomach with risk of maldigestion 7. GERD 8. Decreased absorption of fat, carbs, protein, vitamin B12, iron, folate, calcium, and vitamin D 9. Constipation, flatulence 10. Risk of fecal impaction 11. Risk of adverse drug reactions 12. Cholecystolithiasis (gallstones)

Constipation nursing management (3)

1. Increase physical activity -*important intervention to stimulate colon motility & bowel evacuation through movement of the body* -walking 20 or 30 min is helpful, especially after a meal -pelvic tilt exercises & ROM exercises are beneficial for those who are less mobile 2. Positioning -*squatting or sitting position facilitates bowel function. Similar position may be obtained by leaning forward* & applying firm pressure to lower abdomen or by *placing the feet on a stool* -rocking back and forth may facilitate BM 3. Toileting regimen -*establishing a routine for toileting*, like going at the same time everyday, *promotes or nomalizes bowel function* -bc there is a lot of variation between individuals & their BM routine, it's important to know baseline to be able to determine if there's any changes -gastrocolic reflex *occurs after breakfast or dinner; good time to attempt a BM is about 30 min after these meals.* -allow at least 10 min for a BM 4. Increase fluid intake - at least 1.5 L per day (2-3 L is best; older adults *need just as much water as younger adults*) 5. Increase dietary fiber -*dried fruits, dried beans, vegetables, & wheat products* 6. Laxatives 7. *Enemas = LAST RESORT* -should NOT be used on a regular basis bc a person can become dependent on it & can actually cause constipation -bc enemas cause diarrhea, it may alter fluid & electrolyte status -*sodium phosphate enemas are contraindicated; should be tap water only*

Glaucoma manifestations

1. Initially no symptoms at the beginning of the disease process 2. *Have reduced peripheral vision* (initially subtle) which can progress to --> 3. *Tunnel vision* 4. Blurred vision 5. Halos *around lights* 6. Eye or brow pain from increased IOP

5 Developmental theories

1. Jung -*Extroversion to Introversion* -Focus on *outward achievement shifts to self acceptance* -Psyche and search for personal meaning/spiritual self - *continuous search for "true self"* 2. Erikson -Widely accepted by nursing - eight-stages -Ego integrity vs. despair in older adults -Later Erikson changed his either/or to suggest BALANCE 3. Peck -Extension of Erickson's final stage -Ego differentiation vs. work role perception - *person no longer defined as life work role* (parental or occupational) -Body transcendence vs. body preoccupation - body changes accepted, no longer identity (*not absorbed by health problems or physical limitations from aging*) -Ego transcendence vs. ego preoccupation - self is part of greater whole (*reflection on past life and accomplishments* not "what's left") 4. Maslow -Widely accepted by nursing -Includes bio/psycho/social needs -*Hierarchy of needs* (physiological, safety, love/belonging, esteem, self actualization) 5. Tornstam -*Gerotranscendence (look back on life positively)* -Aging is moving from birth to death and maturation *toward wisdom* -Looking inside (withdrawing) & *spiritual reflection can lead to wisdom*

How to identify if client is having difficulty swallowing

1. Labored swallowing (takes effort to swallow) 2. Coughing or choking 3. Increased oral secretions 4. Pocketing food in mouth -can mean 2 things: they're putting food in cheeks or literally putting food in their pockets to make you think that they're eating 5. Increased eating time 6. Throat clearing 7. Pain 8. Hiccups 9. Chest pain 10. Gurgly voice -not normal & indicates a problem. Need to teach pt not to talk with mouth full 11. Frequent respiratory infections 12. Spitting *Nurse will most likely be the first to detect that a person is having difficulty swallowing*

Heart failure types

1. Left-side: *pump failure to body, backs up in lungs causing pulmonary congestion* -results from inability of left ventricle to empty adequately during systole (*decreased contractility; can't squeeze*) or fill adequately during diastole (*decreased filling; can't relax*) -DYSPNEA 2. Right side: *pump failure to lungs, backs up in tissues* -occurs when right ventricle fails to pump effectively. When the RV fails, fluid backs up into venous system. This causes movement of fluid into tissues & organs. -results from left-side failure -EDEMA & ASCITES 3. Congested HF (acute decompensated) -*have both respiratory & peripheral symptoms. BOTH sides of the heart are congested.* -Swelling, edema, fluid in lungs (pulmonary edema) -Look for: *tachycardia, S3 or S4 gallop, crackles, & dependent edema.*

Effective assessment of older adult requires the nurse to: (6)

1. Listen patiently 2. Allow for pauses -*can take older adults longer to respond & to process questions, especially if they have any cognitive decline or mental impairment* -in clinical practice, when an older adult doesn't respond to a question we immediately ask them in different words & say it louder BUT we just need to give them extra time -*DO NOT assume that an older person can't hear you. Talk in a normal tone & if they say "what" then you speak up* (this can be done as a baseline assessment) 3. Ask questions -closed ended questions are necessary when performing an assessment. For example, "do you have HTN" 4. Observe minute details 5. Obtain data from all sources 6. Recognize normal changes associated with late life

Types of loss in older age

1. Loss of relationships -Significant others -Social contacts -Illness -Death -Distance -Decreased mobility 2. Life transitions -Roles -Financial security -Independence -Health -Mental stability *Loss is not just death in older adults*

Where to find & compare options for LTC facilities

1. MDS - Minimum Data Set 2. QAPI - Quality Assurance Performance Improvement 3. Nursing Home Compare - 5-Star 4. Advancing Excellence in America's Nursing Homes 5. INTERACT - Interventions to Reduce Acute Care Transfers There's a medicare website to show different ratings - usually the higher the rating, the more expensive it is

Cultural variations & abuse - Latino

1. Machismo - expectation of men to *neglect self based on behalf of others* 2. marianismo - role expectation of women to *tolerate abuse and focus on others* 3. Veguenza - need to protect family from shame 4. La familia - emphasis on the family instead of outsiders -*extreme level of guilt not to provide care to elders at home regardless of the difficulty to do so*

Drug-food interactions (4)

1. Many foods interact with meds, producing increased, decreased, or variable effects. -they may also bind to meds, affecting their absorption. -ex: *calcium in dairy will bind to levothyroxine, tetracycline, and ciprofloxacin*, greatly decreasing their absorption - *SHOULD BE TAKEN ON EMPTY STOMACH* 2. Grapefruit juice contains substances that inhibit CYP3A-mediated metabolism in the gut & bind with the statins used for cholesterol lowering meds, clopidogrel, & other meds -altered metabolism & elimination can increase concentration of drug -*Avoid amiodarone, lovastain, simvastatin, buspirone* 3. Green, leafy vegetables (kale, spinach, broccoli) -*contain vit. K which is the antidote for warfarin* -keep intake consistent 4. High potassium diet -potassium-sparing diuretics (spironolactone), increases potassium reabsorption -if a patient ingests a diet high in potassium (salt substitutes, molasses, oranges, bananas) or other potassium sparing agents (lisinopril) at the same time, *potassium can rise significantly & reach toxic levels* -*risk for hyperkalemia* -keep intake consistent

Sleep hygiene (10)

1. Maximize comfort 2. *Bedroom is for two things only - sleep & sex* -shouldn't be watching tv or eating in bedroom bc then brain thinks the room is for more than sleeping 3. Avoid or limit naps -*don't want them taking more than 1 nap per day & it should be 30 min or less* 4. Exercise and outdoor time -should NOT be exercising right before bed. -*exercise during the day can increase sleep* 5. Bedtime routine -at the same time everyday, teach them to begin getting ready for bed & do the same thing every night; gets body in mode for sleep 6. Avoid stimulants and ETOH, esp late in day 7. Manage GERD -GERD can wake person up. Person lays down & has water brash (episode of reflux coming up back of throat & can even cause aspiration) 8. Avoid screen time just before bed 9. If can't fall asleep, get up and go to another room until feeling sleepy 10. Older adults should avoid sleep aids in general -if needed, Melatonin or zolpidem (Ambien) is best; however, *ambien can cause profound sleepiness* & the person may sleep for a very long time, esp when they first start taking it -*sleep walking is also common when taking ambien (older adults are at risk for falls)* -*melatonin is safer/has less side effects*

Federal government provides majority of care via its insurance plans:

1. Medicare 2. Railroad Medicare 3. Medicaid 4. TRICARE (for those who have served in the military) 5. Veterans Administration

Cognition & mood assessment tools

1. Mini-Mental State Examination (MMSE) -screen for & monitor cognitive function -*30 item test used to rule out dementia; NOT a diagnosis* -*if results are negative, can say pt doesn't have dementia* -tests orientation, short-term memory and attention, calculation ability, language & construction -*must be able to read, write, & be english proficient* 2. MMSE-2 -*less specific & quicker* -ask questions like what day is today, what is this (pointing to eye)

Substance abuse concerns

1. Misuse of prescription and OTC medications -some drugs have serious CNS depressive effects that are exacerbated in older adults -*there is a high rate of prescription misuse & abuse in the older population* 2. Polypharmacy effects exacerbated with alcohol use 3. Inappropriate prescribing and ineffective monitoring of controlled substances

CV disease & sexual function

1. Most men have no change in physical effects on sexual function; one fourth may not resume sexual function. 2. Women don't experience sexual dysfunction after a heart attack 3. *Have fear of another heart attack or death during sex; SOB* 4. post MI: those able to engage in mild to moderate physical activity without symptoms can generally resume sexual activity; those with a complicated MI may need to resume sexual activity over a longer a period of time 5. avoid large meals several hrs before sex 6. *stop and rest if chest pain is experienced*, take nitroglycerin if prescribed, and seek emergency tx for sustained chest pain

8 Musculoskeletal changes

1. Narrowed intervertebral disks 2. Decreased cortical & trabecular bone mass 3. Lean body mass replaced with redistribution of fat 4. Decrease in mass & regeneration of muscle fibers 5. Increased latency/contraction time of muscle 6. Increased hip/knee flexion 7. Tendon & ligament stiffening 8. Changes in joints - Articular cartilage erosion; increased bone overgrowths & calcium deposits -*a bone spur is a bony growth formed on a normal bone; bone spurs press against tissues surrounding it & can cause pain & reduced mobility*

OA 7 most common locations

1. Neck - cervical spine 2. Lower back - lumbar spine 3. Hips 4. Hands 5. Fingers 6. Thumbs 7. Knees

Interventions to maintain hydration

1. Need at least 1.5-2 L per day -person may not know how much this is, so *teach them 8 8oz cups of fluid per day* 2. Offer fluids often 3. Make fluids readily available 4. Encourage fluids with meds 5. Provide preferred fluids -if they won't drink water but they'll drink tea, give them tea 6. Verbal reminders

Physiological changes of the aging brain

1. Neuron loss - most pronounced in cerebral cortex -as a result of neuronal loss, the brain itself can shrink. The brain also shrinks bc of less hydration 2. Brain atrophy - decreased weight 3. Dendrites atrophy -*Impaired synapses results in impaired communication between neurons* -Changed transmission of dopamine, serotonin & acetylcholine *Physiological changes are NOT consistent with deteriorating mental function*

Diabetes & sexual function

1. Neuropathy and/or vascular damage may interfere with erectile ability 2. women have less sexual desire and vaginal lubrication 3. decrease in orgasms/absence of orgasm can occur; local genital infection interventions: 1. suggest alternative forms of sexual expression 2. recommend immediate treatment of genital infections

Thermoregulation (3)

1. Neurosensory changes: *diminished or delayed perception of temp changes*; may not feel it's getting hot or cold 2. Physiological changes: *impaired cooling & warming responses to temp changes* (shivering & sweating) 3. Medications & alcohol: impair vasomotor response, inhibit neuromuscular activity, suppress metabolic heat generation, and/or dull awareness of surroundings -older adults are *more sensitive to meds & alcohol that may cause alteration in temp.* -for example, *risk of malignant hyperthermia with antipsychotics is increased*

COPD & sexual function

1. No direct impairment, although affected by coughing, exertional dyspnea, positions, & activity intolerance 2. Meds may lead to erectile difficulties Interventions: 1. encourage sexual activity when energy is highest 2. use alternative positions, pillows 3. plan sex at time meds are most effective 4. suggest use of oxygen before, during, or after 5. teach partner to observe for breathing difficulty

Distribution of lipophilic (fat-soluble) & water soluble meds

1. Normal changes with aging include *lower total body water and higher body fat (as fat replaces lean tissue)*. -Lipophilic meds pass through capillary membranes easily & concentrate in adipose tissue to a greater extent than in other tissues. -*If the med accumulates to an excess in the adipose tissue, it may increase med effect & can result in fatal overdose* 2. The decreased amount of body water found in normal aging *leads to higher serum concentrations of water-soluble meds such as digoxin, ethanol & aminoglycosides*

Stages of AD - Mild cognitive impairment

1. Noticeable cognitive changes 2. *Difficulty managing money = one of the first changes of cognitive function* 3. ↑ Forgetfulness -Appointments -Social engagements -Lose train of thought 4. Decision making becomes overwhelming 5. Trouble finding way around -can be very dangerous, especially with driving 6. Impulsive 7. Depression 8. Irritability/aggression -stereotype that older adults are more irritable; *if a person becomes cranky later in life, they are either unhappy or can possibly have new onset MCI* 9. Anxiety 10. Apathy

Interventions for elder abuse - evidence collection

1. Observe for obvious bruises or body marks 2. Observe and ask about medications 3. Looks for signs of restraints 4. Note body odor, dirty clothing or body, or other signs of neglect 5. Observe for pressure ulcers, dehydration, or malnutrition 6. Photograph injuries and general conditions (follow facility policy)

Health history 4 components

1. Past medical history 2. Review of symptoms 3. Medication history -Prescribed, OTC, "Home remedies", & herbals/dietary supplements -*must ask specifically about meds* 4. Social history - living arrangements, resources, & support systems -*asking are you able to take care of yourself, does someone else help take care of you, who is your social support, do you have family* -when asking an older adult if they can take good care of themselves *they will most likely say yes. They don't want their independence taken away*

Reproductive changes & assessment (4)

1. Perineal muscle weakness 2. Decreased testosterone (sperm count decreases but continues) & estrogen (menopause) 3. Libido does NOT change 4. Vaginal wall thinning

Signs of abuse

1. Physical abuse: -unexplained bruising or lacerations in unusual areas in various stages of healing -fractures inconsistent with functional ability 2. Sexual abuse: -bruises or scratches in the genital or breast area -fear or an unusual amount of anxiety r/t either routine or necessary exam of the anogenital area -torn undergarments or presence of blood 3. Medical abuse: -unusual delay between the beginning of a health problem and when help is sought -repeated missed appointments without reasonable explanations 4. Psychological abuse: -caregiver does all of the talking in a situation, even though the elder is capable -caregiver appears angry, frustrated, or indifferent while the elder appears hesitant or frightened -caregiver or the care recipient aggressive toward one another or the nurse 5. Neglect by self or caregiver: -weight loss -uncharacteristically neglected grooming -evidence of malnutrition and dehydration -fecal/urine smell -inappropriate clothing to the situation or weather -insect infestation

Health assessment of older adults includes: (6)

1. Physical data 2. Biological 3. Cultural - religion, beliefs, practices 4. Psychosocial - family relationships, social activities 5. Functional aspects - physiological & anatomical 6. Growth & development Should be doing comprehensive assessments on all clients, especially older adults. Looking at pt in a holistic fashion - complete health history & assessment

Types of abuse

1. Physical: use of physical force that results in the threat of or the infliction of bodily injury, physical pain, or impairment -striking, pushing, shaking, pinching, & burning 2. Sexual: nonconsensual sexual contact of any kind 3. Emotional or psychological: infliction of anguish, pain, or distress through verbal or nonverbal acts, including intimidation or enforced social isolation 4. Medical: subjecting a person to unwanted medical treatments or procedures 5. Financial or material-exploitation: illegal or improper use of another's funds, property, or assets. -Exploitation may be accomplished through coercion, such as demanding that the person sign checks or documents, including deeds of property, with the threat of withholding care 6. Discrimination 7. Abandonment

Sedation at end of life

1. Physician assisted suicide is illegal in most states 2. Sedation for treatment of symptoms is appropriate and managed by nurses 3. Palliative sedation: giving sedation and pain medication -Give as much as needed -Even if it does speed death -*Death is not the goal, comfort is*

GU changes 7 nursing interventions

1. Preparation for fluid/electrolyte correction as indicated 2. Calculation of creatinine clearance/Cockcroft-Gault equation 3. Safety precautions in nocturnal or urgent voiding & postural hypotension 4. Monitor for nephrotoxic drugs, suggest change or alteration in dose (P&T) 5. Teach pt about bladder training (Void Q2-3h) 6. Kegel exercises - teach to men & women by telling them to use the same muscle they would use to stop themselves from urinating 7. Fluid intake 2-3L/day unless contraindicated (heart failure)

PD 9 nursing interventions

1. Preservation of functional ability and quality of life 2. Increased independence and ADLs -teaching interventions to perform ADLs & maximizing independence is important as a nurse bc people with PD often lose their independence & aren't able to live alone. 3. Prevent complications and excess disability 4. Coping mechanisms 5. Increased socialization 6. Support groups for patient and family 7. Physical therapy and balance training 8. Increase strength and ROM 9. Occupational therapy with adaptive equipment

Hypothyroidism general nursing care

1. Prevent chilling 2. Prevent constipation -Hydration, high fiber, stool softeners 3. Lower dose of sedatives and opioids -*more sensitive due to low metabolic rate* 4. Assess and report signs of cardiac complications 5. Increased risk for infection 6. Assess for edema 7. Frequent turning: at increased risk of skin breakdown 8. *Take Synthroid on an empty stomach 30 min-1h before or 2h after meals* -*may need to wait longer than 2h in older adults bc of slowed gastric emptying* 9. Assess/report tachycardia on Synthroid 10. Limit Iodine on Synthroid -*want synthroid to be all that we're using to regulate T3 & T4* -*if person has hypothyroidism bc of thyroidectomy, they would keep their iodine intake normal* 11. Life long therapy of Synthroid 12. May cause Dig toxicity - Synthroid

Chronic illness trajectory - 8 phases

1. Preventive phase (pre-trajectory): *no signs or symptoms* -person may be younger, preventing chronic disease by eating well, exercising 2. Definitive phase (trajectory onset): *signs & symptoms & diagnosis PRESENT* 3. Crisis phase: *life-threatening* situation 4. Acute phase: *active illness requiring hospitalization* 5. Stable phase: *controlled illness* 6. Unstable phase: *not controlled, but not requiring hospitalization* -ex: blood glucose level of 160 -many people with HTN or high cholesterol are not frequently stable 7. Downward phase: *progressive decline* -person is becoming more frail with their chronic disease 8. Dying phase: chronic illness is causing person to die; *immediate weeks/days/hrs before death*

13 Lab changes in the older adult

1. RBC—Production ↓'d -speed at which the new blood cells can be produced in late life is reduced (decreased marrow reserve) 2. H/H—*Changes with nutrition & fluid status* -usually rise & fall with RBCs -*elevations in hgb and hct are often early signs of hypovolemia from malnutrition, dehydration, or severe diarrhea* 3. WBC—Change may be *absent or delayed with infection*; immunity aging theory -WBCs don't respond as quickly which can lead to worsening of infection 4. ESR ↑'d -*ESR indicates inflammation & is higher in elderly* 5. Vitamins B,C -*water soluble vitamins; reduction indicates acute malnutrition* 6. Vitamins A,E,B12,K -fat soluble vitamins; *reduction caused by long-term malnutrition* 7. Vitamin D↓'d 8. Sodium↓'d -Low intake, altered ADH, increased H2O. -*Sodium decreased in pt's in long term care facilities - concerned with patient's hydration, can result in hyponatremia* 9. Potassium -alterations result from medications & changes in endocrine system 10. Calcium ↓'d -Increased bone resorption: *99% of calcium is stored in bone; older adult has breakdown of bone mass, therefore calcium is pulled from blood to bone causing a decrease in calcium levels* 11. Glucose -Low is most dangerous -Insulin, malnutrition -*signs of hypoglycemia are often masked in older adults; elderly don't sweat as often* -*more frequent episodes of hypoglycemia result in less noticeable symptoms* 12. Albumin—↓'d -albumin is protein; *indicates chronic malnutrition* -Prealbumin indicates *acute malnutrition* 13. PSA (prostate specific antigen)- limited use (>75 and high risk) -*can be elevated by a number of conditions, not just prostate cancer; indicates inflammation of prostate gland*

Thermoregulation - health promotion (4)

1. Recognition of clinical signs of hyperthermia and hypothermia 2. *Monitoring of body temperatures against baseline* in older adults 3. Establish surveillance system for community dwelling older adult clients 4. Social service referrals for assistance with heating and electrical bills

7 phases of retirement

1. Remote: future anticipation with little real planning 2. Near: preparation and fantasizing regarding retirement 3. Honeymoon: euphoria and testing of the fantasies 4. Disenchantment: letdown, boredom, sometimes depression 5. Reorientation: developing a realistic and satisfactory lifestyle 6. Stability: personal investment in meaningful activities 7. Termination: loss of role resulting from illness or return to work

Respiratory assessment (9)

1. Respirations - patterns, breath sounds throughout lung fields 2. Note thorax appearance, chest expansion 3. Assess cough, deep breathing, exercise capacity 4. Assess for infections, asthma 5. Monitor ABGs, pulse oximetry 6. Monitor secretions, sedation, positioning which can reduce ventilation/oxygenation -*oversedation will result in diminished cough reflex, diminished RR, & increases their risk of infection* 7. Activity tolerance 8. Assess for abnormal breath sounds (crackles, rhonchi, wheezing) 9. Assess skin color

8 interventions to prevent dysphagia

1. Seated and rested before eating 2. Sitting up at 90 degrees 3. Don't rush meals 4. Alternate solids and liquids 5. Thickened liquids and pureed foods 6. Avoid sedatives 7. Keep suction readily available 8. Oral care

Older LGBT people are less likely to:

1. Seek out health services 2. Identify themselves as LGBT to health care providers 3. Often have differing or augmented healthcare needs 4. Older LGBT more likely to have kept their relationships hidden than younger people -National Gay and Lesbian Task Force Aging Initiative estimates that about 3 million Americans over the age of 65 are lesbian, gay, bisexual, and transgender, and likely to double by 2030 -May face real or perceived discrimination in senior centers or long term care facilities

Important components of health assessment for older adults

1. Self-report of functional status 2. Home assessment -*#1 thing we're concerned about with older adults is safety in their homes* 3. Psychological aspects -Cognitive -Emotional: *older adults have higher rates of depression & social isolation, so need to ask specifically about these things* -medicare says that *every time an older adult visits their HCP they MUST be screened for depression* 4. Roles - caregiver, family structure -ask, "do you care for someone else?" *often, older adults do care for someone else. It could be their spouse, sibling, or even an older parent.* 5. Decision-makers in family

Nervous system changes 8 CM

1. Slowed thought processing response to stimuli, reflexes 2. decreased ability to respond to multiple stimuli & manage multiple tasks correctly 3. *decreased proprioception (unconscious perception of movement & spatial orientation); potential for extrapyramidal parkinson-like gait* 4. Increased threshold for light touch & pain sensation 5. ischemic paresthesia in extremities common 6. risk of poor balance, postural hypotension, falls, injury 7. great individual variation in cognitive functioning with aging; limited memory impairment, stable crystallized intelligence, some cognitive decline -*confusion is NEVER normal* 8. Risk of mild cognitive impairment, dementia -stimulate brain to prevent alzheimer's

4 Physiological changes in older adults affecting PO absorption

1. Slower GI motility -*caught in esophagus & longer exposure in small intestine* -this additional time for contact of the med with the intestinal walls increases the risk for adverse reactions & unpredictable effects. 2. Decreased salivation -*a dry mouth will reduce or delay buccal absorption* -rectal administration as alternative 3. Decreased gastric pH -slow the action of acid-dependent meds. -some enteric coated meds, such as aspirin, which are specifically meant to bypass stomach acidity, *may be delayed so long that their action begins in the stomach & may cause gastric irritation or nausea* 4. Decreased liver function -*give meds in LOWER doses; risk of becoming toxic bc of decreased drug metabolism* -first pass effect

Metabolism

1. Some meds must be metabolized (broken down) before therapeutic effects are reached -biotransformation (chemical alteration of chemicals) 2. Duration of action -half-life: time it takes 50% of the medication to become inactive -often slow in older due to physiologic changes 3. CYP450 system -enzyme essential for metabolizing many different meds -about 50 different CYP450 types -lots of variability between people; *does NOT seem to be affected by aging*

7 diagnostic studies of thyroid function

1. Thyroid stimulating hormone (TSH) -Released from pituitary -when thyroid is not producing enough TH (T3 & T4), the negative feedback mechanism will communicate to thyroid to produce more. Therefore, will see an ELEVATED TSH bc the purpose of TSH is to stimulate production of T3 & T4 -*hypothyroidism: have a low T3 & T4 & elevated TSH* -*hyperthyroidism: have a high T3 & T4*; pituitary is not going to produce much TSH bc it is not needed, so *will see a LOW TSH level* 2. Thyrotropin-releasing hormone stimulation test (TRH) -TRH injected and TSH measured to assess thyroid function 3. Radioactive Iodine uptake (RAI) -Direct test of thyroid function Radioactive iodine absorbed by thyroid and thyroid can be visualized assessing for nodules -reason iodine is used is bc *iodine is a precursor to thyroid hormone & is soaked up by the thyroid gland* -*TH has a high affinity to iodine & is needed in the diet in order to produce TH* 4. Thyroid scan -Similar to RAI, but *iodine not used.* Radioactive isotopes given orally and taken up by thyroid and visualized on scan. 5. T4 -Generally bound to proteins -Free T4 measures T4 not bound to proteins therefore active -Released by thyroid gland 6. T3 -Monitor the effectiveness of thyroid replacement therapy 7. Thyroxine-binding globulin (TBG) -Helps distinguish between hyperthyroid with ↑T4 and those clients with normal thyroid function who have excess TBG causing an increase in total T4 with normal free T4.

Antipsychotics (3)

1. Used to treat psychosis; sometimes as mood stabilizers 2. MOA centered on blocking dopamine receptor pathways in the brain -also *affect the hypothalamic & thermoregulatory pathways* -often ranked in relation to their side effects, especially *sedation, hypotension, & extrapyramidal (and anticholinergic) side effects* -side effects of anticholinergics: constipation, dry mouth, blurred vision, dizziness, urinary retention, altered mental status 3. typical vs atypical -first meds to be produced are referred to as typical (haldol, thorazine) -second generation meds referred to as atypical (risperidone, seroquel)

Exercise safety

1. Wear comfy loose fitting clothing that absorbs sweat & appropriate shoes 2. warm up for 5-10 min 3. drink water before, during, after 4. never wear rubber or plastic suits 5. Stop exercising if you: have CP, break out in a cold sweat, feel dizzy/sick, have muscle cramps, feel acute pain in joints, have trouble breathing (need to slow down) 6. Times exercising shouldn't be done: 2 hrs after a big meal, when you have a fever/infection accompanied by muscle aches, if BP is 200/100, if joint is red/warm/painful, if you experience pain/swelling in joint, if you have a symptom not yet evaluated by HCP, avoid stretches that flex spine if you have OP

Personal spirituality questions for reflection for nurses

1. What do I believe in? 2. How do I find purpose and meaning in my life? 3. How do I take care of my physical, emotional, and spiritual needs? 4. What are my hopes and dreams? 5. Who do I love, and who loves me? 6. How am I with others? 7. What would I change about my relationships? 8. Am I willing to heal relationships that trouble me?

Interventions for wandering or exiting behaviors

1. face person and make eye contact 2. gently touch person's arm, shoulders, back, or waist if they won't move away from door 3. call person by formal name 4. listen to what the person is communicating verbally & nonverbally 5. identify agenda/plan of action and emotional needs being expressed 6. respond to feelings, staying calm 7. repeat specific words/phrases 8. if repetition fails to distract the person and increases distress, stop talking 9. redirect person toward facility or home at intervals 10. if redirection fails, continue to walk but allowing person control by ensuring safety 11. have a backup person 12. have someone call for help if unable to redirect

Signs of undue influence

1. actions inconsistent with his or her life history 2. makes sudden changes with regard to financial management 3. elder changes his or her will and previous disposition of assets 4. elder is taken to practitioners different from those he or she has always trusted 5. elder is systematically isolated from or is continually monitored when with others who care about him or her 6. someone unexpectedly moves into the person's home, or the elder is moved into someone's home under the guise of providing better care 7. someone attempts to get income checks directed differently from the usual arrangement 8. documents are suddenly signed frequently as the elder nears death 9. a history of mistrust exists in the elders family, and the elder places unusual trust in newfound acquaintances 10. statements of the elder and the alleged abuser vary concerning the elder's affairs or disposition of assets 11. a power imbalance exists between parties in matters of finances or health 12. the stronger person unduly benefits by the transaction 13. the elder is never left alone with anyone. No one is allowed to speak to the elder without the alleged abuser having a way of finding out about it 14. unusual patterns arise in the elders finances 15. the elders reports meeting a "wonderful new friend who makes me feel young again." the elder then becomes suspicious of family and begins to avoid family gatherings 16. the elder is pressed into a transaction without being given time to reflect or contact trusted advisors

Cardiovascular assessment (5)

1. assess BP (lying, sitting, standing) & pulse pressures -*take orthostatic BP to detect hypovolemia* -pt should be lying flat for a few min, then sit them up. Wait at least a min before taking BP after switching positions -note altered landmarks, distant heart sounds, difficulty in isolating point of maximum intensity (mitral valve; 5th intercostal space, midclavicular line) -mitral valve/apex may sound muffled in older adult bc of enlarged heart; *PMI may shift to the left - shift stethoscope to left to hear* 2. assess carotid arteries, right internal jugular vein, varicosities. 3. monitor ECG 4. assess exercise tolerance 5. assess heart sounds, weight, edema, temp, skin color -*cool & pale indicates decreased perfusion* -*edema in lower extremities indicates decreased blood flow*

Communicating with elders who have visual impairment

1. assess for vision loss 2. make sure you have the person's attention before speaking 3. clearly identify yourself and others with you. State when you are leaving to make sure the person is aware of your departure. 4. position yourself at the person's level when speaking 5. when others are present, address the visually impaired person by prefacing remarks with his or her name or a light touch on the arm 6. ensure adequate lighting and eliminate glare 7. select colors for paint, furniture, pictures with rich intensity (red, orange) 8. use large, dark, evenly spaced printing 9. use contrast in printed material 10. use a night light in bathroom and hallways 11. do not change room arrangement or the arrangement of personal items without explanations 12. if in a hospital or nursing home, use some means to identify patients who are visually impaired and include visual impairment in the plan of care 13. use the analogy of a clock face to help locate objects 14. label eye glasses and have a spare pair if possible; make sure glasses worn are clean 15. be aware of low-vision assistive devices such as talking watches, talking books, and magnifiers and facilitate access to these resources 16. if the person is blind, ask the person how you can help 17. recommend screening for vision loss and annual dilated eye exams for older people

Hierarchy of dying person's needs

1. biological & physical integrity: to obtain relief from physical symptoms, conserve energy, & be free from pain 2. safety & security: to be given the opportunity to voice hidden fears, trust those who care for him or her, feel that he or she is being told the truth, & be secure 3. belonging & attachment: to talk, be listened to with understanding, be loved & to share love, to be with a caring person when dying 4. self-esteem & self-efficacy: to maintain respect in the face of increasing weakness, maintain independence, feel like a normal person, & preserve personal identity 5. self-actualization & transcendence: to share & come to terms with the unavoidable future & perceive meaning in death

Home safety evaluation - problems & interventions for steps

1. cannot handle: stair glide, lift, ramp 2. no hand rails: install at least on one side 3. loose rugs: remove or nail down to wooden steps 4. difficult to see: adequate lighting, mark edge of steps with bright colored tape 5. unable to use walker on stairs: keep 2nd walker or wheelchair at top or bottom of stairs

Who is more likely to be abused or neglected?

1. cognitive impairment, especially with aggressive features 2. dependent on abuser 3. physically or mentally frail 4. having abused the caregiver earlier in life 5. women either living alone or in a household with family members 6. having been abused in the past 7. behavior that is considered aggressive, demanding, or unappreciative 8. living in an institutional setting 9. feeling deserving of abuse down to own inadequacies

Common mental disorders in late life are:

1. depression & anxiety 2. mood disorders 3. alcohol abuse and dependence

Home safety evaluation - problems & interventions for safety

1. difficulty locking doors: remote controlled door lock, door wedge, hook and chain locks 2. difficulty opening door and knowing who is there: automatic door openers, level doorknob handles, intercom at door 3. opening & closing windows: lever and crank handles 4. can't hear alarms: blinking lights, vibrating surfaces

Preventing fires & burns (9)

1. do not smoke in bed or when sleepy 2. when cooking, do not wear loose fitting clothing 3. set thermostats for water heater or faucets so that the water does not become too hot 4. install a portable hand fire extinguisher in the kitchen 5. keep access to outside door unobstructed 6. identify emergency exits in public buildings 7. if considering entering a boarding or foster home, check to see that it has smoke detectors, a sprinkler system, & fire extinguishers 8. wear clothing that is nonflammable or treated with a permanent fire-retardant finish 9. use several electrical outlets rather than overloading one outlet

Recommendations to avoid individuals with dementia getting lost

1. don't leave person alone in home 2. secure environment 3. if living in a nursing facility, keep in a supervised area 4. camouflage/disguise doorways 5. place locks out of reach, hide keys, lock windows 6. consider motion detectors or home security system 7. let neighbors know that a person with dementia lives in neighborhood 8. prepare a team in case person becomes lost 9. keep up-to-date photos 10. conduct search immediately if person becomes lost 11. if not found within 6-12 hrs, search wooded areas or fields

10 nursing skills needed for the practice of palliative/end-of-life care

1. have ability to talk to parents and families about dying 2. be knowledgeable about symptom control & pain-control techniques 3. have ability to provide comfort-oriented nursing interventions 4. recognize physical changes that precede imminent death 5. deal with own feelings 6. deal with angry patients & families 7. be knowledgeable & deal with the ethical issues in administering end-of-life palliative therapies 8. be knowledgeable, and inform patients about advanced directives 9. be knowledgeable of the legal issues in administering end-of-life palliative care 10. be adaptive & sensitive to religious & cultural perspectives

Cerumen removal procedure

1. if the cerumen is somewhat dry and close to the canal opening, it may be easily removed with the use of a curette. Gently scoop the cerumen and bring it forward, being careful to avoid scratching the canal 2. once the cerumen is slightly extended from the canal, it can be removed easily with the use of forceps or clamps 3. reexamine the canal for remaining cerumen 4. if the cerumen is hard and can't be removed easily, it may be necessary to soften it before further removal. Softening agents may be instilled into the ear before the removal attempt using mineral or olive oil, commercial products, or a liquid stool softener twice daily for 1-2 days 5. alternatively, hydrogen peroxide may be instilled and allowed to soften the wax several min before the removal is attempted. The patient will tell you when the "bubbling has stopped"

9 Cardiovascular changes

1. increased heart weight; left ventricle hypertrophy (enlargement) 2. decreased baroreceptor sensitivity -baroreceptors sense change in pressure -decrease in sensitivity puts older pt *at risk for orthostatic hypotension bc baroreceptors don't respond to change in pressure* 3. Decreased force of contraction, contractile efficiency, stroke volume -results in decreased output, *putting pt at risk for decreased perfusion & orthostatic hypotension* 4. valvular sclerosis -*valve thickening & hardening causes backup of blood, leading to decreased output & CHF* 5. decrease in pacemaker cells (in the SA node; generate electrical impulses & controls HR) -*decreased electrical activity results in decreased HR* -may have to treat with a pacemaker 6. decreased beta adrenergic response -catecholamines, epinephrine, norepinephrine -- needed for compensation. If decreased, can't compensate as well with changes in pressure -*exercise & stressors stimulate sympathetic output to increase HR, contractility & relaxation, & decrease afterload.* -decreased response results in *reduction in cardiac output & determines exercise capacity* -at risk for orthostatic hypotension 7. arterial stiffening & wall thickening with decreased compliance *(arteriosclerosis)* -increased systolic BP, pulse pressure, & peripheral resistance 8. dilated aorta & tortuous veins -due to increase in afterload & BP; *can increase risk for aortic aneurysm* -veins become less elastic & more weak, therefore *blood has difficulty passing through veins.* -*increased risk for clots & varicosities* 9. decreased O2 uptake by tissues -*risk for ischemia* increased

Interventions to prevent delirium

1. know baseline mental status & functional abilities 2. *assess mental status using MMSE & CAM* 3. correct underlying physiological alterations 4. compensate for sensory deficits (hearing aids, glasses) 5. encourage fluid intake 6. avoid long periods of NPO 7. explain all actions with clear and consistent communication 8. avoid multiple meds & problematic meds 9. be vigilant for drug reactions or interactions 10. avoid sleep meds; use warm milk, music, herbal tea 11. avoid excessive bedrest 12. find out why behavior is occurring rather than simply medicating for it 13. encourage participation in ADLs 14. minimize use of catheters, restraints, or immobilizing devices 15. hide tubes or use intermittent fluid administration 16. activate bed and chair alarms 17. place pt near nurses station for close observation 18. assess and treat pain 19. pay attention to environmental noise, light, temp 20. normalize environment 21. minimize number of room/facility changes 22. do not place 2 delirious pts in 1 room 23. have someone stay with pt

Respiratory changes 11 CM

1. kyphosis (forward curvature of the upper spine); barrel-shaped chest -kyphosis will *alter the location of the lobes & can cause compression of the lungs resulting in decreased ventilation & perfusion* -*reduction in breath sounds* on assessment -*barrel shaped chest results from COPD/emphysema from air trapping* (normal is 2:1, barrel shaped is 1:1) 2. respiratory rate 12-24 -higher resting RR to compensate 3. decreased respiratory excursion & chest/lung expansion with *less effective exhalation & increased residual volume* 4. *Diminished breath sounds particularly at lung bases bc of consolidation* - get pt moving, use incentive spirometer (don't change goal of meter bc person is older) 5. decreased cough, deep-breathing, mucus/foreign matter clearance - *GREATER RISK OF INFECTION & ASTHMA* -infection may not be noticed until severe 6. altered pulmonary function 7. lower maximal expiratory flow (FEV, FEV1/FVC1) 8. reduced vital capacity 9. unchanged total lung capacity 10. dyspnea on exertion, decreased exercise tolerance 11. *PO2, SpO2 decreased* -Decreased capacity to maintain acid-base balance -*hypoxemia: oxygen in blood; measure using PO2*. PO2 indicates lungs are absorbing oxygen -*hypoxia: oxygen in tissues; use SpO2*. SpO2 indicates the ability of the tissues to take up oxygen

Prevention of elder mistreatment

1. make professionals aware of potentially abusive situations 2. help families develop and nurture informal support systems 3. link families with support groups 4. teach families stress management techniques 5. arrange comprehensive care resources 6. provide counseling for troubled families 7. encourage the use of respite care and day care 8. obtain necessary home health care services 9. inform families of resources for meals and transportation 10. encourage caregivers to pursue their individual interests

Health literacy promotion - guiding older adult learners

1. make sure person is ready to learn before trying to teach; watch for cues 2. ensure the person is comfortable; provide pain meds if needed before teaching 3. be sensitive to cultural, language, health literacy level, and other differences 4. provide adequate timing for learning, & use self-pacing techniques 5. create a shame-free environment where older adult feels free to ask questions 6. provide regular positive feedback 7. avoid distractions 8. present pertinent info; emphasize concrete rather than abstract material 9. use past experience 10. use plain language 11. use high contrast on visuals 12. pay attention to reading ability 13. use bullets or lists 14. sit facing the client 15. speak slowly with low pitch 16. encourage mnemonic devices 17. use shorter sessions with frequent breaks 18. use teach-back methods

Myths about sex & older women

1. masturbation is an immature activity of youngsters and adolescents, not older women 2. sexual prowess and desire wane during the climacteric, and menopause is the death of a woman's sexuality 3. hysterectomy creates a physical disability that results in the inability to function sexually 4. sex has no role in the lives of older people, except as perversion or remembrance of times past 5. sexual expression in old age is taboo 6. older people are too old and frail to engage in sex 7. the young are considered lusty and virile; elders are considered lecherous 8. sex is unimportant or over in the lives of the older individuals 9. older women do not wish to discuss their sexuality with professionals

Arthritis & sexual function

1. pain 2. fatigue 3. limited motion 4. Steroid therapy may decrease sexual interest or desire Interventions: 1. advise pt to perform sexual activity at time of day when less fatigued and most relaxed 2. suggest use of analgesics and other pain relief methods before sex 3. encourage use of relaxation techniques

Physical activity & exercise participation

1. provide appropriate screening before beginning an exercise program 2. assess functional abilities & how exercise can enhance them 3. provide info about benefits of exercise 4. clarify misconceptions (fatigue, injury) 5. assess barriers & how to overcome 6. provide an "exercise prescription" 7. set short term & long term goals 8. encourage use of journal to reflect 9. provide choices 10. provide self-monitoring methods to visualize progress 11. try to make it fun & entertaining; group or buddy may make it more successful 12. discuss side effects & what should be reported 13. provide safety tips 14. begin with low intensity for sedentary individuals 15. low intensity activities in short sessions & include warm up & cool down with active stretching (teach importance of this); progression from low to moderate intensity is important for max benefits 16. encourage use of proper well-fitted footwear 17. lifestyle activities can build endurance when performed for at least 10 min

10 health benefits of physical activity

1. reduced risk of HTN, CAD, MI, stroke, diabetes, colon & breast cancers, metabolic syndrome, depression 2. reduced adverse blood lipid profile 3. prevention of weight gain 4. improved cardiorespiratory & muscular fitness 5. reduced risk of falls & hip fracture 6. improved sleep quality 7. improved bone & functional health 8. decreased risk of early death 9. improved functional independence 10. improvement in walking speed, strength, functional ability

Home safety evaluation - problems & interventions for bedroom

1. rolling bed: remove wheels, block against wall 2. bed too low: leg extensions, block, 2nd mattress 3. lighting: bedside light, night light, flashlight on walker or cane 4. remove sliding rugs, tack down, rubber back, two-sided tape 5. slippery floor: nonskid wax, no wax, rubber sole footwear, indoor-outdoor carpet 6. thick rug edge/doorsill: metal strip at edge, remove doorsill, tape down edge 7. nighttime calls: bedside phone, cordless phone, cell phone -phone difficult to hear: headset, speaker phone -phone difficult to dial: preset numbers, large buttons, voice activated

Nurses can provide spiritual comfort by:

1. sharing caring words 2. reminiscence 3. listening to life stories 4. validating their lives 5. praying with and for 6. reading scripture 7. referring clergy 8. providing for religious objects and rituals

Elderspeak may be characterized by:

1. simplistic vocabulary and grammar 2. shortened sentences 3. slowed speech 4. elevated pitch and volume 5. inappropriate terms of endearment - sweetie, baby 6. speaking as if person is not there 7. using familiar/informal communication without permission 8. using the "royal we" - "how are we doing today?"

7 respiratory changes

1. thorax & vertebra rigid -vertebra like the ribs become stiff & not as flexible 2. decreased muscle strength & endurance -*diaphragm & intercostal muscles decrease in size & strength* 3. diminished ciliary & macrophage activity -*purpose of ciliary & macrophages in the lungs is to prevent infection*; therefore, older adults are at increased risk for infections like bronchitis, pneumonia, TB 4. increased airway reactivity -*more sensitive cough reflex, increased chance of wheezes, spasms* 5. drier mucus membranes -mucus membranes are supposed to produce fluids & secretions to help prevent infection by getting things out more easily *(dry mucus membranes --> increased risk of infection)* 6. decreased alveolar function, vascularization, & elastic recoil -*less blood flow from alveoli results in decreased gas exchange, decreased absorption of O2, & reduced expulsion of carbon dioxide* 7. decreased response to hypoxia & hypercapnia -*compensate for hypoxia by taking a deep breath/yawning; this mechanism is not intact in older adults* -*hypercapnia results from decreased absorption of O2 & retained CO2* from not being able to breathe as deeply

3 types of urinary incontinence

1. urge -*overactive bladder* -defined as *8 or more episodes of incontinence per day, nocturia, & urgency* 2. stress -from *increased intraabdominal pressure* (sneezing, coughing, laughing) -defined as *leakage of 50mL or more* 3. functional -nothing wrong with urinary tract (urge & stress there is a physiologic reason) -*just can't get to restroom for some reason*

Hearing aid care & use

1. when first purchased, advisable to wear for 15-20 min per day until one is adjusted to the new sounds 2. gradually increase wearing time to 10-12 hours 3. make sure fingers are dry and clean before handling hearing aids. Use a soft dry cloth to wipe your hearing aids 4. each day, remove any earwax that has accumulated on the hearing aids. Use the brush that is included with the aid to clean difficult-to-reach areas 5. adjust the volume for differing environments 6. avoid getting the aid wet; do not wear when swimming or taking a shower or bath 7. avoid use around fine particles that can clog the microphone such as hair spray, make up, or blowing sand and dirt 8. many aids will slowly decrease in volume and may make a "peep" when it is time to change the battery. -Check the battery by turning the hearing aid on, turning up the volume, cupping your hand over the ear mold, and listening. -A constant whistling sound indicates that the battery is functioning. -A weak sound indicates that the battery is losing power and needs replacement 9. be sure to remove the battery and return the aid to its case when not in use

Reducing fire risks in the home (9)

1. when you smell smoke, see flames, or hear the sound of fire, evacuate everyone before doing anything else 2. use normal exits unless blocked 3. make sure smoke alarms are installed on each level of home & outside all sleeping areas; test alarms monthly & replace batteries at least once a year 4. know at least 2 exits from every room 5. make necessary accommodations, such as providing exit ramps & widening doorways to facilitate an emergency exit 6. contact local fire dept nonemergency number and explain special needs 7. in high-risk apt, remain in the room with doors & hall vents closed unless smoke is in apt. open or break window to obtain fresh air 8. rehearse what to do if clothing catches on fire: do not run. If another persons clothing is burning, smothers the flames with the hardiest item 9. if you live in a multistory home, arrange to sleep on the ground floor near an exit

What has the most significant effect on pharmacokinetics in the aging body?

Age-related changes in renal function: 1. ↓ Glomerular filtration rate -a decrease in GFR reduces the body's ability to excrete or eliminate meds in a timely manner* -leads to prolongation of the half life & results in *more opportunities for accumulation, overdose, & potential toxicity* 2. ↓ Active tubular secretion 3. ↓ Passive tubular reabsorption 4. ↓ kidney size -the GFR can be approximated by creatinine clearance & helps with dosing

________ have the shortest life span

Black men - only expected to reach their very early 70s In regards to older men, we tend to make assumptions about social/economic status - think they have resources like a pension or 401k but this is not always true

1/3 of adults in their ______ have no retirement plans

50s Young adults are advised to begin retirement planning as soon as possible Middle adults (40-50) MUST do retirement planning

Restraints & side rails

A restraint is any device that limits the movement of a person *Try not to use restraints in older adults EVER if possible.* Consequences of restraints in older adults: 1. *DOES NOT effectively prevent falls, wandering, or removing medical equipment* (IVs, monitors) 2. Restraints *can actually exacerbate the problem & make it worse* 3. Restraint-related death: a *big problem with restraints is a risk for asphyxiation* (cutting off the airway) & can lead to death. 4. Restraints *increase the risk of pressure ulcers, agitation, cognitive decline, & depression.* 5. Side rails are not simply a part of the bed - they're a type of restraint if 2 full length rails are up or 4 half length rails are up -*requires a HCP order* 6. Research evidence does not show side rails reduce falls or injury -some evidence that they may increase injury -the more side rails that are up, the more dangerous the bed is. Can lead to falls if person is trying to get up & climbs over rails 7. CMS requires documentation of need for side rails

An older African-American client reports to the nurse that his hearing has been getting worse recently. Which action should the nurse perform first? A. Assess the client's ear canals. B. Ask the client if he has any tinnitus. C. Assess the client's middle ears. D. Ask the client if he has ever had otosclerosis.

A. Assess the client's ear canals.

The nurse performs a Katz assessment of Independence in Activities of Daily Living (IADL) on an 81 year old male client. The nurse evaluates that the client exhibits independence if he does which of the following? (Select all that apply) A. Bathes self each day B. Needs help wiping after toileting C. Makes it to restroom without incontinence D. Needs help while eating E. Dresses self each day

A. Bathes self each day C. Makes it to restroom without incontinence E. Dresses self each day

Which activity assures the nurse that the client's wish to, "leave a living legacy" has been accomplished? A. Donating their body to the local teaching hospital for research purposes B. Discussing their experiences as a World War II veteran in Europe to a reporter C. Keeping a journal to be passed on to their great-grandchildren D. Making a pilgrimage to a location with personal religious significance

A. Donating their body to the local teaching hospital for research purposes

The nurse responds to an older client who is suspected of experiencing heat fatigue at an outdoor event. What is the priority nursing intervention? A. Transfer the client inside a cool building B. Place the client in a dorsal recumbent position C. Assess the client's last incidence of urination D. Assess client's skin on the chest for tenting

A. Transfer the client inside a cool building

_________ are at higher risk for developing glaucoma

African Americans Glaucoma prevention: 1. Yearly eye exam for 65 and older 2. Report signs & symptoms immediately 3. African Americans should begin having yearly eye exams YOUNGER (55-60) bc they're at higher risk Nursing interventions: 1. Eye provider follow up - collaboration with ophthalmologist or optometrist 2. Ongoing questions and vision testing 3. Care surrounding medication management

________________ results from the development of neurofibrillary tangles in brain consisting of protein tau and extracellular deposits of amyloid-β peptides (plaques)

Alzheimer's disease (AD) -Loss of connections between nerve cells and death of these nerve cells -Research is ongoing -AD is the *6th leading cause of death and 3rd most expensive medical condition*

Malnutrition

Another type of geriatric syndrome 1. Rising incidence of malnutrition in acute care, long-term care, & in the community 2. *Institutionalized older adults are at high risk for malnutrition due to chronic disease and functional impairments* -when a person requires another person to physically feed them in order to get nutrition, they are at very high risk for malnutrition 3. Malnutrition increases risk of infection, pressure ulcers, anemia, hip fractures, hypotension, impaired cognition and increased morbidity and mortality 4. Comprehensive screening and assessment is critical to identify older adults at risk

Coenzyme Q 10 is a powerful ________ used to reduce risk of what?

Antioxidant; MI, improve HR & BP -mixed evidence 1. *Most common use*: -*Along with statins (statins reduce natural levels of CoQ10)* 2. SEs: Overall *tolerated well*; some Gi upset 3. *Increase effectiveness of antihypertensives (monitor BP)* 4. *Reduce effectiveness of anticoagulants*

Dehydration nursing management

Assess signs of dehydration: 1. Skin turgor (unreliable) 2. Weight 3. Mucous membranes 4. Speech changes 5. Tachycardia 6. Decreased urinary output 7. Dark urine 8. Weakness 9. Dry axilla 10. Sunken eyes *Many of these signs are unreliable in older people* (decrease in skin turgor as a physiologic change associated with aging, changes in sweating, etc) -Assessment of hydration needs to be holistic; must look at overall picture -If dehydration is suspected in an older adult, *can't diagnose based on a physical exam; labs must be drawn to see what electrolyte balances are - generally always confirmed with lab testing*

Substance abuse assessment & interventions

Assessment: 1. Screening for alcohol and drug use 2. *Comorbid conditions may mask decline caused by alcohol* Interventions: 1. Must address quality of life and adapt to meet needs of older adult 2. Treatment focuses on cognitive and behavioral approaches 3. Screening for alcohol and drug abuse 4. Education and counseling about alcohol and prescription, OTC, and illicit drug use -illicit drug use DOES occur in older adults; *substance abuse will typically follow a person into old age. However, late onset alcohol use is more common* 5. Referral to specialists and community resources

Other clinical signs of PD (autonomic & cognitive dysfunction)

Autonomic dysfunction 1. Seborrhea dermatitis: dry, flaky scalp 2. Hyperhydrosis of face and neck: excessive sweating 3. Heat intolerance 4. Postural hypotension 5. Constipation -has to do with slowed motility 6. Complications: skin breakdown, dizziness, falls, impaction Cognitive & psychologic dysfunction 1. Dementia -from changes of dopamine in the brain 2. Memory loss, lack of problem solving, decreased intellect 3. Anxiety 4. Depression -anxiety & depression can be bc of changes in neurotransmitters but also highly r/t person's manifestations. 5. Complications: Loss of function, social isolation -*changes in walking & communication can cause person to become very self-conscious & result in social isolation* 6. Sleep/wake reversal 7. Visual disturbances 8. Psychosis

TedEd q - What was the overwhelming reaction to the Respecting Patient Choices program at John Hunter Hospital? A. Patients and their families were uncomfortable with the idea of discussing death B. Patients and their families appreciated the program and though it should be normal hospital practice C. Patients and their families were so enthusiastic about the program that they continued the dialogue even after funding ran out D. Patients and their families voiced frustration at the hospital's inability to fulfill their wishes

B. Patients and their families appreciated the program and though it should be normal hospital practice

The partner of a client states, "Our sex life will certainly suffer now that he's had a heart attack." Which statement is the basis for the nurse's response? A. The client should no longer have sexual relations because of the demand on his heart. B. People with heart disease reduce their sexual activity out of fear of their condition. C. The energy expenditure during sex is equivalent to briskly climbing six flights of stairs. D. The couple will benefit from attending a cardiac support group.

B. People with heart disease reduce their sexual activity out of fear of their condition.

OP pharmacological therapy to prevent bone loss

Bisphosphonates -Boneva -Used to treat OP; *causes reabsorption of calcium into the bone from the blood* -99% of body's calcium is in the bone; 1% is in the blood -*Major complication of bisphosphonates is degeneration of the jaw* -Often people who take this will have tooth loss bc calcium is being pulled out; will cause a change in jaw/mandible & person will have fractures & degeneration Nursing considerations for administration: 1. Should be *taken with a FULL glass of water, in the morning, on an empty stomach* 2. Patient *must sit upright for at LEAST 30 min* after taking the med -can't take med & go lay down or recline in the chair; have to be standing or sitting -Reason for this is bc the medication *must dissolve in the acidic environment of the stomach to become active* -*if med gets stuck in esophagus, it becomes inactive & has a higher risk of esophagitis*

The client with Alzheimer's disease begins to act aggressively when being shown old family photos by the son. The nurse should next perform which action? A. Assess for fatigue B. Ask the son the leave C. Ask the son to put the pictures away D. Administer the PRN anti-anxiety medication

C. Ask the son to put the pictures away

TedEd q - What surprised Peter Saul during his interaction with Jim and Kathleen? A. Jim had such a severe case of pneumonia that he could not talk B. Kathleen wanted everything possible to be done to help Jim C. Jim and Kathleen had never discussed the possibility of Jim becoming sick or dying D. Jim had lived to 94

C. Jim and Kathleen had never discussed the possibility of Jim becoming sick or dying

An older client who is at risk for falling has multiple throw rugs in the home. The nurse performs which action to best eliminate the risk of falling? A. Tack down the rugs to the floor B. Apply rubber backing to the rugs C. Remove the rugs from the home D. Apply two-sided tape to the rugs

C. Remove the rugs from the home

11 GU changes

Changes in renal function begin at age 40 & decrease in function by 10% every decade 1. Maintenance of baseline homeostasis for fluid/electrolyte balances 2. Decreased functional reserve when water/salt overload/deficit 3. Decreased kidney weight, blood flow, oxygenation, glomerular filtration rate (often < 50%, measured by creatinine clearance) -*GFR is the best indicator of renal function* -*creatinine is more specific to renal function than BUN* 4. Tubule degeneration -Reduced response to ADH --> risk of dehydration -Impaired capacity to dilute, concentrate, acidify urine; impaired sodium regulation -*neutral/alkaline urine seen in older adults, increasing their risk of infection*. 5. Reduced bladder elasticity, muscle tone, capacity 6. Detrusor instability with involuntary bladder contractions 7. Weakened urinary sphincter 8. Decreased or delayed perception of voiding signal 9. Increased nocturnal urine production 10. In males, decreased prostatic antibacterial factor; risk of benign prostatic hyperplasia (BPH) 11. In post-menopausal females: estrogen loss; decreased pelvic area elasticity; gland & epithelial atrophy; alkaline vaginal pH -*vagina normally acidic to prevent infection; therefore elderly women are at higher risk for infection* -epithelial atrophy can cause painful intercourse & tearing, bleeding, or uterine prolapse

What factors influence sexual behaviors of older adults?

Cultural, biological, psychosocial, environmental factors 1. Factors affecting attitudes on intimacy and sexuality include family dynamics and upbringing, cultural and religious beliefs 2. Era in which a person was born influences attitudes about sexuality 3. *Current older people often uncomfortable talking about sex/sexuality* 4. *Baby boomers more open*

Jean is a 68-year-old woman who has moved to the United States with her partner, Suzanne, whom she met in the Peace Corps. She has been diagnosed with stage IV ovarian cancer with liver metastasis and has a very poor prognosis. Jean is being seen by the palliative care service for symptom management. She has declined chemotherapy and is hopeful that she will be able to return home soon. When asked about her religious affiliation, she replies that she is "SBNR - spiritual but not religious." In planning Jean's palliative care, in collaboration with interdisciplinary colleagues, what is the best approach? A. Contact the chaplain; perhaps Jean is angry or in denial, given her prognosis, and in need of a conversation about religious faith B. Don't ask any further questions about spirituality, and document in the medical record that no one should discuss spirituality C. Leave religious materials in Jean's room in case her religious views will change as she faces death D. Further assess Jean's spiritual well-being and offer support consistent with her values and beliefs

D. Further assess Jean's spiritual well-being and offer support consistent with her values and beliefs

The most appropriate way for the nurse to communicate with a hearing impaired older adult is to: A. speak loudly into the unaffected ear. B. speak with a higher pitched voice. C. provide all communication in written form. D. speak clearly and directly while facing the person.

D. speak clearly and directly while facing the person.

Positive orthostatic change

Decrease in systolic BP of 10 or more; increase in HR of 10 or more

Culturally competent encounter

Determine the following about the elder: 1. preferred cultural, ethnic, and racial identity 2. expectations concerning formality of the encounter 3. expectations concerning use of names, titles, addressing the patient and the nurse 4. preferred language 5. level of health and reading literacy and availability of assistance if needed 6. past personal experience with the western healthcare model 7. level of acculturation, adherence to traditional approaches, openness to new approaches 8. factors influencing decision-making: who, how, when, what

Minimum data set 3.0 (MDS)

Developed by medicare & medicaid services; *comprehensive assessment of long term care facilities used to plan, monitor, and describe the care delivered to residents* -Evidenced-based measures for pain, cognition, delirium, depression, ADLs; *includes resident interviews* -are facilities assessing for residents' changes in cognition, their pain, etc. *Multi-disciplinary tool that focuses on PT, social work, & nursing care*

Theory-based interventions (3)

Development of nursing philosophy of care come from psychosocial & developmental theories -used as basis to develop policies Examples: 1. Prioritization of care - Maslow -Basic needs and safety met first in order to assist client to progress to the next level 2. Free radical theory - for many years it was *thought that consumption of supplemental antioxidants (such as vit. C & E) could delay or minimize effects of aging by counteracting the oxidative stress caused by free radicals.* It's *now known that the intake of supplemental antioxidants is deleterious* to one's health -*diets included with natural antioxidants (fruits & veggies) have been found to be healthful* 3. *Finding ways for all persons to have access to nutritious food is an important nursing intervention*

Diagnosis of cataracts & treatment

Diagnosed with an eye exam & history - typically can see the cataract or white discoloration of the lens with the naked eye *Treatment = surgical replacement of the lens* -take lens out & replace it with an artificial, plastic lens. -*done when vision is 20/50 or worse* -QOL or safety is an issue -outpatient -*one eye done at a time* bc the eye has to be patched & in case of complications Nursing care peri-op: 1. Prepare for changes in vision post-op 2. *Avoid heavy lifting, straining, and bending* 3. Eye drops (antibiotic drops put in post-op) 4. Eye shield/patch

What is considered last-line treatment for depression in older adults?

Electric compulsive therapy (ECT) -*only used if the older adult has exhausted all of their options but is still having high degrees of depression & suicidal ideations* -Safe therapy for older patients at risk for harm due to suicidal ideation, psychotic depression, or severe malnutrition -Efficacy rates ranging from 60%-80%

A _____________ is one's tangible and intangible assets that are transferred to another and may be treasured as a symbol of immortality

Legacy -Purpose of legacies is to supersede death -Older people must be encouraged to identify that which they would like to leave and who they wish recipients to be

Hypothyroidism diagnosis & treatment

Diagnosis 1. TSH, T3, T4, FT4 2. Physical exam & history; Cardiac studies to assess complications Treatment *Thyroid replacement hormone: Levothyroxine (Synthroid)* -*synthetic T4 (converted to T3 in tissues once ingested)* -Difference in bioavailability with levothyroxine & synthroid; *CANNOT switch without permission from HCP* -Common SEs: All those *signs of HYPERTHYROIDISM* -Serious SEs: Dysrhythmias, CHF, HTN, angina, seizures Nursing considerations 1. Assess for bleeding in pts on anticoagulants -*interacts with warfarin & other anticoagulants & potentiates the action, increasing the risk for bleeding* 2. Hyperglycemia *(need for increased DM treatments)* 3. *NOT used as a wt loss med.* -can cause thyrotoxicosis or cardiac effects like a-fib 4. Long half-life 5. *Give on empty stomach* (opposite of hyper)

Glaucoma diagnostics & treatment

Diagnostics: 1. Vision exam 2. *Tonometry* -tests IOP 3. Other advanced exams Treatment is focused on reducing IOP through: 1. Surgery -Argon laser trabeculoplasty (ALT) -Opens outflow channels to increase the outflow of aqueous humor 2. Medications -PO or eye drops -*lower IOP by increasing drainage of aqueous humor or reducing aqueous humor production* -*beta blocker drops = first line treatment*

Models of care

Different ways of focusing on improving care 1. PACE: Program for All Inclusive Care for the Elderly 2. NICHE: Nurses Improving Care for Health system Elders -program that is usually in a hospital; specialized unit delivers care to older adults 3. ACE: Acute Care for the Elderly -similar to the NICHE program 4. Culture Change -homelike, care and activities are directed by the residents, relationships among staff and residents are supported and fostered 5. Transitional Care -promotes the safe & timely transfer of patients from one level of care or setting to another -Med mgmt., discharge planning/teaching, etc. (RNs and APRNs)

Cognitive assessment

Evaluation of cognition requires formal focused assessment Complete assessment, including laboratory workup, should be performed to *rule out any medical causes of cognitive impairment* -need to look at several things: *stress, medications, labs, organ dysfunction*

Hypernatremia 9 symptoms

Serum sodium > 148 mEq/L *think dehydration* 1. orthostatic hypotension 2. increased thirst 3. poor skin turgor 4. dry mucus membranes 5. weight loss 6. oliguria 7. lethargy 8. hyperthermia 9. elevated BUN, Hct, creatinine

Age-related changes in water & body fat cause _______ blood alcohol levels

HIGHER 1. the older adult has less overall body water & the greater the amount of dehydration, the greater the effects of alcohol. 2. Liver and kidney function interferes with alcohol metabolism and excretion -liver becomes less efficient & shrinks in size -kidneys, which are responsible for excreting & metabolizing products of alcohol, are slowed 3. Increased risk of gastrointestinal bleeding

______ is the MOST COMMON CV chronic condition in people > 65 yo.

HTN -HTN is a complex disease with a core defect of vascular dysfunction that leads to target organ damage. -*Purpose of keeping BP under control is to limit end organ damage.* High blood flow organs like the kidneys, brain, & heart are especially affected. *JNC recommendation for 60 yrs or older: BP is OK if LESS THAN 150 SBP OR 90 DBP* (this is the top limit; technically want them in 140 over 80s) -Reason this changed was bc older adults are more sensitive to CV meds & orthostatic hypotension. When the limit was 140/90, older adults were bottoming out & having adverse events. -Also, not as worried about effects of HTN in someone who is in their 90's bc of the life span. Not trying to increase their yrs, but trying to improve the quality of the yrs they have left

___________ is the most common cause for hospitalization, re-hospitalization, and disability for those over 65 yo

Heart failure 1. Results from damage from *HTN & coronary heart disease.* 2. Heart loses ability to effectively pump. The heart cannot provide sufficient blood to meet the O2 needs of tissues & organs 3. Ventricles *ENLARGE & DILATE* -*results in weaker muscle* -heart can become enlarged in older adults even without HF as part of the aging process -causes decreased/distant heart sounds & *PMI may be shifted to the left* Also related to: Alcohol & drug abuse, chronic hyperthyroidism, & valvular disease

_________ is also known as thyrotoxicosis

Hyperthyroidism -*not as common as hypothyroidism is in older adults*, but still a high rate of it compared to other disorders Causes: 1. Autoimmune disorder (Grave's disease) -*most common cause* 2. Multinodular goiter -enlarged thyroid or nodules on thyroid that are producing extra TH. 3. *Greatly affects women more than men; 5-7:1 (both thyroid disorders do)* Patho: 1. Increased circulating thyroid hormones (increased T3, T4) --> 2. metabolic rate increases --> 3. heightened sensitivity to catecholamines (increased epinephrine, adrenaline) --> 5. manifestations of hyperthyroidism

___________________ is a decrease in smell acuity

Hyposmia -results from a decrease in neurons that send signals to the brain -difficulty distinguishing smells -decrease in taste secondary to change in smell acuity

_________ is referred to as myxedema in adults & cretinism in infants

Hypothyroidism -affects more women than men (5:1) between ages 30-60; has a slow onset Causes: Primary 1. Genetic/congenital 2. tx for hyperthyroidism 3. thyroiditis 4. iodine deficiency 5. decreased TH produced 6. *Can be caused by medications such as amiodarone, anabolic steroids, lithium, phenytoin, beta blockers* Secondary -Pituitary TSH deficiency or peripheral resistance to thyroid hormones

Pharmacodynamics in older adults (4)

Less reliable & more unpredictable Noteworthy meds: 1. anticholinergics: *can increase rate of functional decline & the risk for accidental injury* -can't pee (urinary retention), can't see (dry eyes/blurred vision), can't spit (dry mouth), can't shh (constipation 2. sympathomimetics/ catecholamines -*exacerbated effects* (salivation, diarrhea, vomiting) 3. diuretics: *reduce baroreceptor response* - higher risk for orthostatic hypotension & volume changes (dehydration) 4. beta agonists & antagonists: reduced effects due to alterations in adrenergic system activity -*sudafed has anticholinergic & sympathomimetic effects; concerned with increased BP & HR with older adults* -also want to try & *AVOID diuretics in older adults; find alternatives*

PD - dopamine precursors & glutamine antagonists

Levodopa (L-dopa), carbidopa-levodopa (Sinemet), amantadine (Symmetrel) -*main meds used to treat PD* 1. Improves manifestations of *motor function* 2. Levodopa is *converted to dopamine* in brain by decarboxylase; it's a dopamine precursor 3. Carbidopa *prevents conversion of dopamine* in peripheral tissues; *given with levodopa to prevent the breakdown of dopamine* -has a *synergistic effect*; enhance effects of one another 4. Amantadine increases CNS response *(makes CNS more sensitive) to dopamine* 5. Side effects *(effects of excess dopamine; reminds you of a person with schizophrenia)* -N/V/D, *arrhythmias*, blurred vision, *darkening of sweat and urine*, dyskinesias, postural hypotension, *hallucinations and vivid dreams* 6. Levodopa is *AVOIDED* in those with *history of TIA, angina, melanoma, & narrow angle glaucoma*

____________ & ___________ may contribute to the development of anxiety disorders in older adults

Life events & stressors

Ginkgo biloba is used to improve:

Memory 1. There is no evidence showing it improves memory; however, people still believe it does 2. SEs: bleeding risk, Gi upset, headache, heart palpitations, dizziness, weakness, constipation, hypotension 3. Contraindications: *Use with anticoagulants (false elevation of INR; warfarin may be decreased), antihypertensives, antidepressants* -*Seizure disorder* 4. Should be approved by healthcare provider -*Most will say to avoid*

What is considered the barometer for health?

Sleep -good measurement of a person's overall health Aging is associated with: 1. decreased sleep quality 2. sleep disorders (apnea, insomnia) 3. Circadian rhythm responses diminished -increase in stage one of sleep (lightest level of sleep; between being awake and falling asleep) & less REM (restful sleep stage) 4. Longer to fall asleep 5. Frequent awakenings 6. Increased napping during the day Must assess sleep patterns *Common myth that older adults don't need as much sleep as younger adults but this is not true - older adults still need about 8 hrs of sleep per night.*

Absorption

Must enter bloodstream to be effective (usually) Time from admin to entry into blood stream - many factors affect, including route, bioavailability & amount of medication Route 1. IV: immediate; directly into bloodstream 2. IM, ID, Rectal, eyes, sublingual, transdermal: quicker 3. PO/enteral: slower (given in higher dose) 4. Transdermal (patches for pain control): more constant & controlled in older adults. Bypass first pass effect (when concentration of drug is greatly reduced before it reaches the systemic circulation) -*thinning, dryness, and roughness of older skin affect absorption of the intended dose* Bioavailability: how much medication is in a tablet. Any small change in dosage can throw a person out of their therapeutic index -*nursing response when pt states that they must be switched from trade to generic: must talk to provider*

Myths about the aging brain

Myth: people lose brain cells everyday & eventually run out Fact: most areas of the brain do not lose brain cells. Although you may lose some nerve connections, it can be apart of the reshaping of the brain that comes with experience Myth: you can't change your brain Fact: the brain is constantly changing in response to experience and learning, and it retains this "plasticity" well into aging. Changing our way of thinking causes corresponding changes in the brain systems involved; that is, your brain believes what you tell it Myth: the brain doesn't make new cells Fact: certain areas of the brain, including the hippocampus (where memories are created) & the olfactory bulb regularly generate new brain cells Myth: memory decline is inevitable as we age Fact: most reach old age and have no memory problems. The incidence of dementia does increase with age, but when there are changes in memory, older people need to be evaluated for possible causes and receive treatment. Myth: there is no point in trying to teach older adults anything Fact: basic intelligence remains unchanged with age, and older adults should be provided with opportunities for continued learning

OA vs. RA

OA: 1. Occurs in older adults; equal in both sexes 2. May be *unilateral* - Knee, hip, spine, hand 3. DIP & PIP joint (distal & peripheral joint) 4. Shorter period of morning stiffness -*goes away within 30 min* 5. *Increased pain with activity* RA: 1. Occurs earlier in life 2. Women > Men 3. *Symmetrical* - hands & feet common 4. MCP & PIP joint 5. *Prolonged morning stiffness > 30 min* 6. *Increased pain with rest or inactivity* *Activity is major treatment for both disorders in preventing complications*

___________ is a decrease in bone density

Osteoporosis -chronic disease of older adults Non-modifiable risk factors: 1. Female gender -*affects women more than men* 2. Caucasian race -*affects those with light skin more than those with dark skin* 3. Northern European 4. Advanced age 5. Family history of osteoporosis Modifiable risk factors: 1. Low body weight 2. Low calcium intake 3. *Estrogen deficiency* -when a woman goes through menopause estrogen production is decreased. *The fastest overall loss of bone mineral density is 5 to 7 years immediately after menopause* 4. Low testosterone 5. Inadequate exercise or activity -as a person exercises, there is pressure/stress on the bones causing them to become harder & stronger. More calcium is pulled into the bone. Reduced activity puts a person more at risk 6. Use of *steroids or anticonvulsants* 7. *Excess coffee or alcohol* intake 8. *Current* cigarette smoking

Older Americans resources & services (OARS)

Overall more comprehensive assessment of: 1. Social resources 2. Economic resources 3. Mental health 4. Physical health 5. ADLs *Aids in establishing degree of need* -Rating of excellent to completely impaired

PLISSIT Model as guide for discussion of sexuality in older adults

P - *permission* from the client to initiate sexual discussion LI - providing the *limited information* needed to function sexually SS - giving *specific suggestions* for the individual to proceed with sexual relations IT - providing *intensive therapy* surrounding the issues of sexuality for the clients (may mean referral to specialist)

The major complication of PD is _____________

Parkinsonian Crisis -*Precipitated by emotional stress or sudden withdrawal of meds* (person skipped dose or stopped taking meds altogether) -Need to identify underlying cause so that it can be addressed -Very likely that person will require hospitalization Manifestations: 1. Severe exacerbation of tremors, rigidity, and bradykinesia 2. Anxiety 3. Sweating 4. Tachycardia 5. Hyperpnea Treatment & interventions: 1. Respiratory/cardiac support prn -*respiratory & CV system are the most important thing to assess* 2. *Non-stimulating environment* -a person having a crisis will most likely be anxious, so need to provide a calm environment, lights turned low, etc. -may have heat intolerance so need to give them a cooler room 3. Psychological support 4. Restarting medications

Medicare part _______ provides insurance coverage for many of the services provided on an outpatient basis, such as visits to providers' offices

Part B -An advantage of this original Part B is a choice of the primary care provider and referrals are not usually necessary. -Providers who accepts assignment have agreed to charge only an allowance fee that medicare determines annually. -The provider receives 80% of this amount from medicare and the patient is responsible for the remaining 20% and any deductible. -A provider who does not accept assignment may charge the patient up to 15% more than allowable charge

Medicare part ______ uses a prospective payment system and includes traditional health maintenance organizations (vision, dental, etc) & other managed care plans

Part C -All traditional services covered by parts A & B must be provided, and additional services, copays, and deductibles are predetermined.

Ginseng has many uses, including what?

Reduce stress, lower LDL, lower glucose, immune stimulant, erectile dysfunction -research is weak to support this 1. SEs: hypertension (possible hypo), risk of bleeding, edema, diarrhea, mania (in those with bipolar) 2. Contraindications: *Use with antidiabetics, anticoagulants, antihypertensives, immunosuppresants, stimulants, MAOIs* 3. Should be approved by healthcare provider

_________ is a chronic systemic inflammatory joint disorder

Rheumatoid arthritis (RA) -*Autoimmune disease* where inflammation of joint lining destroys surrounding cartilage and eventually bone as well -not only in older adults, but *sometimes starts sooner in person's 30's, 40's, or 50's & affects women more than men* -*Systemic: can affect any organ system, not just the joints*. -generally manifestation seen is arthritis, but it can also cause vasculitis, anemia, splenomegaly, pulmonary nodules, pericarditis Focus of research includes 1. Genetic factors 2. Environmental triggers in genetically vulnerable population 3. Hormonal triggers

Crimes against older adults

Risks and Vulnerability: 1. Living alone 2. Memory impairments 3. Loneliness 4. *Older people are more likely to be victims of consumer fraud and scams that include telemarketing fraud, e-mail scams, undelivered services* Fraudulent schemes against alders: -Trusting elderly persons may be duped into giving money to pen pals, Internet acquaintances, phony religious causes, new acquaintances who "need help" -Door-to-door contractors, IRS Impersonators, Medical fraud -*need to teach people to be aware of these things*

PD - MAOB inhibitors (-giline)

Selegiline (Eldepryl), rasagiline (Azilect) 1. *Inhibits the breakdown of dopamine* 2. Often used synergistically with Levodopa 3. Same side effects as dopamine: N/V, dizziness, insomnia, postural hypotension, *HTN at high doses* 4. *Contraindicated with prozac & demerol*

____________ is an ongoing process that ideally continues through adult life as one becomes self-actualized

Self-renewal Involves: 1. Commitment to beliefs 2. Connecting to world 3. Times of solitude -*do not assume that an older adult who is sitting in silence must be depressed; self-reflection can be therapeutic* 4. Episodic breaks from responsibility 5. Contact with natural world 6. Creative self-expression 7. Adaptation to changes 8. Learning from down times

Biological aging is referred to as:

Senescence (latin - "to grow old") -Condition/process of *deterioration with age*

Damage to inner ear or neural pathways results in what type of hearing loss?

Sensorineural 1. Presbycusis: type of sensorineural r/t aging -*Most common* -*Bilateral* 2. Intolerant to loud noises 3. Difficulty in distinguishing between consonants -Z, S, Sh, F, P, K, T, G 3. *Raised voices often exacerbate the problem* 4. *High frequency sounds lost first* 5. Difficulty filtering background noises -Healthcare setting often noisy 6. Treatment -Hearing aids & cochlear implants

Hyponatremia 16 symptoms

Serum sodium < 135 mEq/L 1. hypotension 2. tachycardia 3. hyperthermia 4. nausea 5. malaise 6. lethargy 7. somnolence 8. confusion 9. poor skin turgor 10. increased thirst 11. muscle twitching 12. abdominal cramps 13. headache 14. seizure 15. coma 16. elevated BUN & Hct

_______ is periods of not breathing while sleeping

Sleep apnea Signs & symptoms: 1. excessive daytime sleepiness 2. snoring, gasping, choking 3. headache, irritability -*symptoms often fit stereotypical characteristics of an older adult*, but should not blame on age & need to further investigate 70% of men & 56% of women 65 and older have obstructive sleep apnea (OSA) -many don't have diagnosis & think they just snore a lot -*caused by a decline in the tone of the upper airway muscles,* which *allows the upper airway to close more easily* -sometimes tongue is involved & can cover the airway; that's why when a person is lying on their back they have more episodes of apnea & snoring Treatment: 1. limit/stop alcohol & sedative use 2. lose weight (being overweight contributes to OSA) 3. smoking cessation 4. CPAP (continuous positive airway pressure)

Age related changes in bowel causing constipation

Small intestine: 1. villi become broader, shorter, & less functional; blood flow decreases 2. Proteins, fats, minerals (including calcium), vitamins (esp. b12), and carbs (esp. lactose) are absorbed more slowly & in lesser amounts Large intestine: 1. slowed peristalsis, blunted response to rectal filling, increased collagen deposition leading to dysmotility, fibro-fatty degeneration & increased thickness of the internal anal sphincter

_____________ was set up in 1935 as an "age-entitlement" program by FDR - monetary support available at a certain age regardless of personal resources

Social Security 1. *Funded by payroll taxes - employees & employers* 2. Amount of benefit *calculated on person's average salary during 35 of his/her working years* 3. 2018- average benefit $1404/month (max $2788 @ full retirement age) 4. *Current full benefit age is 65-67 y.o.* - may start at 62 y.o. at reduced benefit amount 5. May earn up to $17,040/yr. via employment if under full retirement age. Unlimited if over full retirement age.

Distribution of protein-bound meds

Some meds are bound to protein for distribution. In healthy adults of any age, *a predictable percentage of an absorbed med is inactivated as it's bound to the protein*. The remaining free med is available in the bloodstream for therapeutic effect when an effective concentration is reached in the plasma. -Older adults at risk of malnutrition & low protein levels -some meds have more & some have less effect; unpredictable -*keep clients nourished*

_________ & _________ are called the "thyroid hormones". Abnormalities of these lead to hyper and hypothyroidism.

T3 & T4

Drug interactions

The more prescribed meds or other substances (herbs, dietary supplements, OTCs) a person takes, the greater the possibility one or more will interact with another -When 2 or more meds (or products of any kind, including food) are given at the same time or closely together, *one substance may potentiate another (cause it to have stronger effects than when given alone) or may antagonize (lower the potency) the other, even to the point that the med is inactivated*

___________ is surgical removal of part or all of thyroid

Thyroidectomy -*reserved for severe case or large goiters* (swelling or enlargement of gland) -high efficacy of meds; *often will have to give person medication for hypothyroidism after removal, hypo is easier to treat than hyper* Pre-op care 1. give antithyroid medication called lugol's solution -it's *potassium iodine & iodide used to decrease thyroid gland perfusion & decrease T3, T4 production* -as gland is cut, TH is released. Bc of this, person has a *high risk of having a thyroid storm or thyrotoxicosis which can be life-threatening* 2. Want to *promote reduction of anxiety* to reduce risk of thyroid storm Post-op care: 1. person is at *high risk for developing respiratory or airway complications* due to airway edema so need to continuously be assessing airway & resp. status 2. *HOB should ALWAYS be up* after surgery, head supported by pillows 3. Pt will have difficulty speaking or have a hoarse voice after surgery; pt *needs to rest voice* 4. *There should be a trach tray available by the bedside in case of airway occlusion* 5. Teach pt to *reduce calorie intake* -bc of manifestations of hyperthyroidism, person probably needed extra calories to maintain a healthy body weight; now they will have either a normal or low metabolic rate 6. *Maintain adequate dietary intake of iodine* 7. *Avoid high temps* bc it can cause person to have more signs of hyperthyroidism even after surgery; person is very sensitive to heat

_____ is the most common cause of sepsis in older adults

UTI -*Often asymptomatic in older adults*. May not have the classic signs such as frequency, burning, urgency. -Cognitively impaired may not report symptoms -Atypical symptoms (not typical, but common in this age group): 1. *mental status change (sudden onset confusion*; this is why it's important to have baseline mental status) 2. decreased appetite 3. incontinence -*Normal for older adults to have asymptomatic, uncomplicated bacteria in urine.* -partially has to do with the change in urine's pH that bacteria can live there more easily -UTI happens when bacteria adheres to the bladder wall & then begins to cause symptoms UTI algorithm: assessment & treatment for UTI in nursing homes

2/3 of older adults over the age of 65 have __________ impairment

Vision impairment 1. Among top 10 causes of disability in US 2. Lower QOL and life expectancy 3. *Low vision (20/40) to legal-blindness (20/200)* -20/40 means that the person can see at 20 feet what the person with normal vision can see at 40 feet. -With 20/200, a person with normal vision can see from 200 feet, what the person with this type of vision can see at 20 feet. -*Nurses screen vision using a Snellen chart* 4. Affects nearly all ADLs 5. Have increased risk of falls & cognitive decline

If it is not possible to remove the wax safely using the curette, a _________ may be effective

Water flush 1. protect clothing and linens with water-proof material 2. follow directions on a commercial ear irrigating product. This usually involves pumping a small amount of water into the canal through a small short cannula, at which time the water reruns into a collection cup with dissolved cerumen (hopefully) 3. before the flush, test the water temp by pumping a few drops on the external ear. *The acceptable temp for the irrigation is highly individual* 4. check the canal frequently for effectiveness & check with the patient for tolerability 5. during the irrigation, the cerumen will either be returned with the water or brought closer to the surface that it can be removed with the curette 6. *any time the patient expresses nausea or dizziness, stop immediately*

PVD - arterial insufficiency

With peripheral arterial disease, arteries are insufficient meaning that *blood is not getting to the extremity as it should*. 1. Inflow problem (hypoperfusion) - blood cannot get to feet 2. Have numbness/tingling 3. *Cool & pale when elevated* 4. Pain is *worse with use* & *improved with dependency/rest* 5. Use an ankle brachial index (ABI): measures pressure in the brachial artery & the posterior tibial artery. It should be about equal. If pressure is lower in the ankle than in the brachial artery, it indicates arterial insufficiency.

An older adult with rheumatoid arthritis reports currently taking echinacea to help with a cold. What is the priority nursing teaching? a. determine if the herb is approved by the FDA b. the herb is generally considered safe in all older adults c. take the herb at least 1 hr after other meds d. discontinue the herb and notify the healthcare provider

d. discontinue the herb and notify the healthcare provider